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Scleritis
Aka: Scleritis, Nodular Scleritis, Necrotizing Scleritis
- See Also
- Sclera
- Episcleritis
- Epidemiology
- Rare
- Pathophysiology
- Severe Scleral inflammation
- Variations
- Nodular Scleritis
- Necrotizing Scleritis (most destructive)
- Anterior Scleritis (deep to Conjunctiva)
- Posterior Scleritis (overlying Retina)
- Causes
- Idiopathic in 50% of cases
- Connective Tissue Disease
- Rheumatoid Arthritis (most common cause)
- Accounts for up to one third of Scleritis cases
- Scleritis occurs in 4-10% of RA cases
- Granulomatosis with Polyangiitis (previously known as Wegener's Granulomatosis)
- Polyarteritis Nodosa
- Systemic Lupus Erythematosus
- Relapsing Polychondritis
- Reiter's Syndrome
- Psoriatic Arthritis
- Ankylosing Spondylitis
- Inflammatory Bowel Disease
- Crohn's Disease
- Ulcerative Colitis
- Infectious (uncommon)
- Herpes Zoster
- Herpes Simplex Virus
- Pseudomonas
- Aspergillus
- Tuberculosis
- Symptoms
- Red Eye involving one or both eyes
- Blurred Vision
- Photophobia
- Subacute course with gradual onset
- Significant Eye Pain (especially Necrotizing Scleritis)
- Deep boring toothace-type Eye Pain
- Pain radiates to eyebrows, cheeks and temples
- Pain worse with eye movments
- Intense night pain with pain on awakening
- Assocated symptoms
- Fever
- Headache
- Vomiting
- Signs
- Decreased Visual Acuity
- Pain on palpation
- Diffuse Eye Redness
- Scleral edema
- Corneal Ulceration
- Scleromalacia (severe cases)
- Sclera thins and takes on a bluish hue
- Signs: Slit Lamp Exam
- Critical to do this exam prior to Fluorescein application
- Fluorescein can settle in the stroma and obscure the Scleritis findings and extent
- Localized, raised hyperemia of Sclera
- Elevated Scleral vessels
- Scleritis does not blanch with topical Phenylephrine
- Phenylephrine blurs Vision for 3 hours
- Phenylephrine contraindicated in Glaucoma
- Avascular areas over Sclera
- Associated Conditions
- Associated with Rheumatologic Conditions in >50% of cases
- Anterior Scleritis
- Iritis
- Glaucoma
- Posterior Scleritis
- Retinal Detachment
- Proptosis
- Differential Diagnosis
- See Red Eye
- Episcleritis
- Conjunctivitis
- Management
- NSAIDs
- Indomethacin 25 mg orally twice daily
- Ibuprofen 600 mg orally three times daily
- Naproxen 250 to 500 mg orally twice daily
- Ophthalmology referral
- Advanced cases may require immunosuppressants and Corticosteroids
- Course
- Duration of months to years
- Complications
- Scleral thinning or perforation
- Staphyloma
- Scleromalacia perforans (in Rheumatoid Arthritis)
- References
- Goldstein in Yanoff (1999) Ophthalmology, p. 13.1
- Ruddy (2001) Kelley's Rheumatology, Saunders, p. 396
- Nakla (1998) Gastroenterol Clin North Am 27:697-711 [PubMed]
- Pflipsen (2016) Am Fam Physician 93(12): 991-8 [PubMed]