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Title: Scleritis

Author: Trey Winter, 1st Year Medical Student, University of Utah

Description: Scleritis is a disorder characterized by the inflammation of the sclera that can radiate to the cornea, episclera, and uveal tract. This inflammation can be destructive, painful, and potentially blinding. It is commonly associated with other systemic diseases such as rheumatoid arthritis.

Scleritis is divided into two main types, anterior scleritis and posterior scleritis. Anterior scleritis is further divided into three categories: diffuse anterior scleritis, nodular anterior scleritis, and necrotizing anterior scleritis.

Diffuse anterior scleritis- the most common, best prognosis.

Scleromalacia or corneal thinning from prior scleritis.

Necrotizing anterior scleritis- least common, most dangerous.

Nodular anterior scleritis- 2nd most common, often recurrent.

Presentation: Scleritis most commonly presents with severe, constant eye pain that worsens at night and in the morning. Movement of the eye is generally painful as the muscles controlling eye movement insert into the sensitized sclera. Patients with scleritis also present with ocular redness, headaches, photophobia, and watering of the eye.

The key sign of scleritis during ocular examination is an injection (an apparent increase in size and number of blood vessels on the sclera), associated with violaceous discoloration of the eye and tenderness to palpation. Although the injection can span multiple layers, involvement of the deep episcleral vascular plexus is what distinguishes scleritis from other, less severe conditions.

Diagnosis: It is important to note that the diagnosis of scleritis involves two aspects: the primary diagnosis of scleritis and the evaluation for a systemic disorder associated with scleritis.

Scleritis can be diagnosed and classified largely based on the information in the history and from the ophthalmologic exam. The ophthalmoscopy and slit-lamp examinations are used to detect deep scleral injection. Tenderness to palpation (done by gently pressing on the eyelid over the area of inflamed sclera) is highly specific to scleritis. A less common but occult form of scleritis known as “posterior scleritis” can present with a normal appearing external eye but instead present with choroidal and posterior scleral thickening on ultrasound.

The most important differential diagnosis is between scleritis and episcleritis. Episcleritis is an inflammation limited to the episclera (the layer superficial to the sclera) and is typically not emergent or vision-threatening. Both conditions present with similar symptoms including redness of the eye and pain. The phenylephrine test can be used to help distinguish these conditions by administering phenylephrine topically to the eye. In cases of episcleritis, the phenylephrine will blanch the eye due to vasoconstriction of the episcleral vessels. The deeper and larger inflamed vessels from sclerits will remain red after administration of the phenylephrine.

A large percentage of true scleritis cases have an underlying, associated systemic inflammatory condition. Here is a truncated list with a brief review of each disease:

Complications: Scleritis can lead to permanent ocular complications in severe cases.

Complications from scleritis include:

Management/Treatment: Treatment of scleritis usually begins with nonsteroidal anti-inflammatory drugs (NSAIDS), especially for diffuse anterior scleritis and nodular anterior scleritis. NSAIDS reduce the stiffness, swelling, and pain associated with scleritis. For necrotizing anterior scleritis and posterior scleritis, glucocorticoids or the combination of glucocorticoids and immunosuppressive agents are administered. In severe cases, patients need surgery to prevent rupture and retain vision.

Treatment is individualized based on the patient’s symptoms and the severity of the symptoms. As mentioned above, it is imperative not to forget a careful history and systemic work-up for any underlying, associated systemic inflammatory conditions.


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Identifier: Moran_CORE_24943

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