Scleritis

Background

  • Potentially blinding disorder
  • Sclera fuses with dura mater and arachnoid sheath of the opic nerve
    • Reason why optic nerve edema and visual compromise are common complications
  • 50% of cases associated with an underlying disorder:
    • RA
    • Granulomatosis w/polyangiitis (Wegners)
    • IBD

Clinical Features

Non-mobile inflammation of entire scleral thickness
  • Essential sign is scleral edema, usually accompanied by violaceous discoloration of the globe
  • Intense ocular pain that radiates to the face
  • Pain with EOM (extraocular muscles insert into the sclera)
  • Photophobia
  • Globe tenderness to palpation
  • Episcleral vessel dilation

DifferentialDiagnosis

Unilateral Red Eye

^Emergent diagnoses

^^Critical diagnoses

Evaluation

  • Labs (to assess possible associated disease)
    • CBC
    • Chemistry
    • Urinalysis
      • Rule-out glomerulonephritis
    • ESR, CRP
  • Posterior Scleritis (posterior to the insertion of the extraocular muscles)
    • Physical exam often benign
      • Inflammation may sometimes be seen at the extremes of gaze
    • Patient complains of pain, pain upon EOM
    • Involvement of the optic nerve and retina is common
      • Retinal detachment, optic disc edema

Imaging

  • Ultrasound and CT can show thickening of the sclera

Management

  • Systemic therapy with NSAIDs, glucocorticoids, or other immunosuppressive drugs
  • NSAIDs

Disposition

  • Urgent ophtho consult

Complications

  • Cornea
    • Peripheral ulcerative keratitis > irreversible loss of vision
  • Uveal tract
    • Anterior uveitis seen in 40%
      • Spillover of inflammation from the sclera
  • Posterior segment
    • Retinal detachment, optic disc edema

See Also

References