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Clinical Summary

Scleritis is painful, destructive, and potentially blinding. The pain is constant and boring and may radiate to the face and periorbital region. Associated features include tearing, photophobia, globe tenderness to palpation, and painful ocular movement.

The conjunctival vessels are injected. The eye itself may be intensely red with a violaceous or purple hue secondary to engorgement of the deep vessels of the episclera and scleral thinning. These deep vessels do not move when the overlying conjunctiva is moved with a cotton-tipped applicator, nor do they blanch with topical phenylephrine. On slit-lamp microscopy, the episcleral vessels are displaced outward by scleral edema. Corneal involvement, iritis (with cells and flare in the anterior chamber), and decreased visual acuity may accompany scleritis. An associated scleritis may occur with severe infectious keratitis. Primary infectious scleritis is rare. In either instance, topical and systemic antibiotics are indicated after appropriate cultures are obtained.

In up to 50% of cases, scleritis is associated with underlying autoimmune or infectious systemic disease, with rheumatoid arthritis being the most common. It occurs more frequently in women and in the 4th to 6th decades of life.

Management and Disposition

Ophthalmology consultation is required. Treatment varies according to underlying disease (if present) and can involve NSAID therapy, glucocorticoids, and immunosuppressive medications. Rheumatology consultation by the ophthalmologist is often required for optimal management in patients with underlying autoimmune disorders.

Pearls

  1. Scleritis is associated with a systemic disease in approximately 50% of cases, most commonly rheumatoid arthritis.

  2. Most cases of scleritis involve the anterior portion (anterior to the insertion of the medial and lateral rectus muscles).

  3. Pain is exacerbated with ocular movements because the extraocular muscles insert into the sclera itself.

  4. Anterior uveitis can occur in up to 40% of patients because the uvea is immediately adjacent to the sclera.

  5. Check intraocular pressure (IOP) to rule out acute ACG as another cause of painful red eye.

FIGURE 2.35

Scleritis. A generalized vascular injection is seen. A bluish hue is also seen superiorly due to scleral thinning. The vessels do not move when the overlying conjunctiva is moved with a cotton-tipped applicator. (Photo contributor: Jeffrey Goshe, MD.)

FIGURE 2.36

Scleritis. A 55-year-old female with scleritis of the left eye associated with rheumatoid arthritis. Note dilation of the deep conjunctival and episcleral vessels and blue hue suggesting thinning of the sclera temporally. (Used with permission from Brice Critser, CRA, The University of Iowa and EyeRounds.org.)

FIGURE 2.37

Sectorial Scleritis. Deep-boring pain experienced by this patient distinguishes this segmental area of erythema from episcleritis. (Photo contributor: Kevin J. Knoop, MD, MS.)

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