SIGNS AND SYMPTOMS
Unlike the mild sensitivity of episcleritis, true scleritis presents with
severe, boring ocular pain which may also involve the adjacent head and facial regions.
The scleral vessels are significantly dilated, as are the overlying vessels of the
episclera and bulbar conjunctiva. The affected eye may be so injected in some cases that
the eye actually takes on a deep red, almost purple, hue. This presentation may be
sectoral or diffuse.
Patients typically report a gradual onset of the pain and redness, with
associated photophobia, tearing and decreased vision. Slip lamp evaluation may reveal
scleral nodules (nodular scleritis), peripheral keratitis and secondary uveitis in some
instances. In severe cases of necrotizing scleritis, the sclera may become transparent due
to chronic inflammation, revealing the underlying dark blue of the choroid.
Scleritis is a primary inflammation of the sclera, which is often (over 50
percent of cases) associated with systemic disease. Among the most common related
disorders are rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus,
polyarteritis nodosa, Wegener's granulomatosis, herpes zoster virus, gout and syphilis.
Unlike episcleritis, the inflammation characteristic of scleritis has
the capacity to spread to other ocular tissues of the anterior segment and/or posterior
segment. Consequently, if you do not begin treatment of scleritis immediately, the
condition poses the risk of severe visual compromise in the form of cataracts, secondary
glaucoma, choroidal or exudative retinal detachment or optic atrophy.
Topical medications alone are generally insufficient in managing scleritis.
In addition to cycloplegia (scopolamine 0.25% BID/QID or atropine 1% BID) and a topical
steroid, scleritis indicates a systemic anti-inflammatory agents as well. Treat moderate
sectoral or diffuse anterior scleritis with oral NSAIDs (e.g., ibuprofen 600mg QID or
indomethacin 25mg TID).
If the inflammation is severe or necrotizing, or if non-steroidals alone
fail to suppress the inflammation, use a systemic steroid such as oral prednisone 80mg QD
for two to three days, then slowly taper to 10 to 20mg daily. It may also be necessary for
patients to receive a small maintenance dose for up to one month to control the condition.
In rare cases, the patient may require immunosuppressive agents and should be managed by a
Treated improperly, scleritis can render a great deal of damage to
the affected eye.
- Be sure to distinguish between this disorder and the less threatening
- Occasionally, an atypical presentation of necrotizing scleritis without
inflammation may occur; this is known as scleromalacia perforans. In this presentation,
the sclera thins significantly in discrete areas, allowing for local outpouchings of the
underlying choroid. There is no recognized treatment for this condition.
- In all cases of scleritis, always consider the underlying cause to be
systemic disease until proven otherwise. Refer patients for a comprehensive medical
evaluation, including serology and radiology studies where appropriate. Specific tests may
include: complete blood count (CBC) with differential, erythrocyte sedimentation rate
(ESR), antinuclear antibody (ANA), HLA-B27, rheumatoid factor (RF), angiotensin-converting
enzyme (ACE), fluorescent treponemal antibody absorption (FTA-ABS), lyme titer, chest
X-ray and sacroiliac joint films.
Other reports in this section
Allergic Conjunctivitis &Vernal
Chlamydial & Gonococcal Conjunctivitis
Superior Limbic Keratoconjunctivitis (SLK of
Conjunctivitis with Pseudomembrane
Giant Papillary Conjunctivitis