Scleritis: definition, presentation, dx tool/PET, management
inflammation of the sclera, the outer covering of the eye [ potentially vision threatening]. May also involve the cornea, adjacent episcleral & uveal tract. Avg age of onset is 48y.
often assoc w. systemic diseases: systemic rheumatologic and inflammatory disorders - Rheumatoid arthritis, Granulomatous w/ polyangiitis, infection
Clinical manifestations
- Anterior scleritis - intense eye pain [ deep, constant pain radiating to head, periorbital area and neck, worse at night/early morning hours], local tenderness to touch, pain is worse with eye movements, edema & deep purple blue [violaceous hue] redness of the sclera [diffuse or local] that is purpuric or deeper in color compared to Conjunctivitis or Episcleritis. **Photophobia and/or vision loss.
- Posterior scleritis happens in the nonvisible portion of the sclera - the eye appears ‘white’ [no redness] and uninflamed on external exam, rather than violaceous or red. Variable amounts of pain [ often severe] and often difficult to localize. Diplopia and pain upon eye movement is common. Reduced vision
Physical examination
- slit lamp exam: scleral edema and profound dilation of the deep episcleral vascular plexus.
- No vessel blanching w/ installation of 2.5% topical PHENYLEPRINE. Episcleral redness improving with instillation of phenylephrine drops suggests Episcleritis vs. Scleritis.
Management of Noninfectious Scleritis
- **Diffuse or nodular scleritis: systemic NSAID [ ex: Indomethacin] initial tx of choice. Topical corticosteroids [ ex: prednisolone acetate 1%] may be added to systemic NSAIDs.
- Necrotizing or posterior scleritis: High-dose Glucocorticoid [ex: Prednisone] w. or without a immunosuppressive’s agent [ ex: Rituximab preferred] OR Cyclophosphamide.
- Pt with suspected scleritis should be referred to Ophthalmology within a few days.
Episcleritis: definition, etiology, presentation and management
localized inflammation of vessel lining of the episcleral [ between the sclera and conjunctiva]
~70% occur in women. most common in young and middle aged adults [ avg 45y]
Etiologies
- Thought to be an autoimmune process- most commonly idiopathic [most have no underlying systemic disease] but may be seen with connective tissues disease
-Autoimmune association: ex: RA, IBD, ANCA vasculitis, SLE, Seronegative spondyloarthropathies.
Manifestations
- Nonpainful localized eye redness without vision loss: abrupt onset of unilateral SECTORAL REDNESS [local erythema confined to 1 quadrant w/ overlying conjunctival vessel injection], irritation and possible watery discharge. May be nodular. pain and vision loss are UNCOMMON.
- Mild if any ocular discomfort [ achiness associated with nodular variant]. Normal visual acuity
- Physical exam: sclera may appear blotchy with areas of bright redness over episcleral vessels.
Management
Asymptomatic
- **tx generally not needed bc it is self-limiting and non-sight threatening **- sx and findings typically resolve spontaneously over several weeks. Ophthalmology follow-up
Symptomatic
1- Topical lubricants and artificial tear preparations that do not contain preservatives [ex: Bion tears, Refresh plus]
2- Topical NSAIDS [ ex: Diclofenac ophth drops 2-4 times daily] if sig discomfort or refractory to topical lubricants, Topical corticosteroids may be used it refractor topical NSAIDS.
3- Topical corticosteroids: Fluorometholone 0.1%, Loteprednol etabonate 0.55, Prednisolone acetate 1%
4- Oral NSAIDS ex: Ibuprofen, Naproxen, Indomethacin. Oral corticosteroids.
