Scleritis is inflammation of the sclera (the fibrous layer of the eye underlying the conjunctiva and episclera). It is haracterized by edema and cellular infiltration of the entire thickness of the sclera.
Classification of immune:
- Anterior nonnecrotizing scleritis: can be subdivided into diffuse or nodular
- Anterior necrotizing scleritis with inflammation: subdivided into vasoocclusive, granulomatous, surgically induced. Aggressive form of scleritis. Average age of onset is 60 yr. Bilateral in 60% of patients
- Scleromalacia perforans: typically affects elderly women with longstanding rheumatoid arthritis
- Posterior scleritis: involves the deeper tissues of the eye and is potentially blinding. Age of onset is often under 40 yr. Bilateral in 35% of cases
- Anterior scleritis
- Diffuse nodular, necrotizing scleritis
- Scleromalacia perforans
- Scleral melt syndrome
PHYSICAL FINDINGS & CLINICAL
- Deep, boring (dull) eye pain that may awaken patient from sleep
- Conjunctival injection
- Thinning of the sclera
- More than 50% of patients have an underlying systemic autoimmune disease. Most common rheumatic problem is rheumatoid arthritis. Most patients with systemic disease are diagnosed before development of scleritis.
- Inflammatory (seen with rheumatoid arthritis, granulomatosis with polyangiitis [Wegener granulomatosis], relapsing polychondritis, polyarteritis nodosa)
- Bisphosponates: risk of scleritis is 50% higher among new bisphosphonate users than among nonusers.
- Infectious scleritis (herpes zoster, tuberculosis, Lyme disease, syphilis, Pseudomonas aeruginosa, Nocardia, leprosy) is uncommon, accounting for 4% to 18% of cases
- Approximately 50% of patients with scleritis have an underlying systemic disease (vasculitis, infectious disease).
- Most common causes are rheumatoid arthritis and other collagen-vascular diseases.
- Occasionally there are allergic, infectious, or traumatic causes.
- Conjunctivitis, iritis, and episcleritis should be considered in the differential diagnosis. Patients with episcleritis generally have less pain and vision is unaffected.
- Fluorescein angiography
- Eye examination
- Visual field examination
- Workup for autoimmune disease
- Workup for vasculitis
- Collagen vascular workup
Rheumatoid factor, antinuclear antibody, erythrocyte sedimentation rate, ANCA (c-ANCA, p-ANCA), antiphospholipid antibodies, may be useful for underlying etiology
Usually not necessary; CT scan of orbit may be useful in selected patients for collagen vascular disease or vasculitis
- Bandage lenses
- Surgery if thinning of the sclera is severe to prevent eye rupture
ACUTE GENERAL Rx
- Steroids (topical, periocular, and systemic)
- Cycloplegic drops
- Nonsteroidal anti-inflammatory drugs (topical and systemic); systemic more effective than topical
- Cytotoxic agents (cyclophosphamide, azathioprine, mycophenolate mofetil, methotrexate)
- Immune modulators (cyclosporin, tacrolimus)
- Specific antibodies (infliximab, rituximab)
- Systemic steroids can be given for the underlying disease.
- Local steroids may be helpful.
- Control underlying disease.