Scleritis

Question 1

Non-pharmacological management

Answer 1

Sunglasses for photophobia

Question 2

Pharmacological management

Answer 2

High dose oral NSAIDs for pain relief.
if NSAIDs contraindicated, give paracetamol.

Question 3

Referral?

Answer 3

YES
If necrotising anterior or posterior scleritis, refer SAME DAY
if non-necrotising anterior scleritis, refer urgently within 1 week.

Question 4

What can they do at hospital?

Answer 4

Investigate for systemic disease
Topical and systemic steroids
Systemic NSAIDs
Oral steroids with immunosuppressive drugs / biologics such as TNFalpha
If infective, micro biological testing
B scan ultrasonography to rule out posterior involvement
Liase with rheumatology

Question 5

Aetiology

Answer 5

Rare but sight threatening disease where there is inflammation of the sclera. Can be categorised into anterior or posterior depending on where the inflammation is. Anterior can be further categorised into diffuse, nodular, and necrotising.

Question 6

Predisposing factors

Answer 6

idiopathic but 30-40% are associated with systemic disease such as RA, lupus, IBS, sjogrens, ankylosing spondylitis. 4-10% of cases are infective in origin e.g. HZO, sarcoidosis, tuberculosis, syphilis, psuedomonas

trauma or surgery

drug-induced - rare but linked with biphosphonates.

Question 7

SINS?

Answer 7

surgery induced necrotising scleritis is a rare complication following surgery such as pterygioectomy, scleral buckle, cataract removal - caused by infection with pseudomonas.

Question 8

Symptoms

Answer 8

Severe eye pain radiating to jaw and brow, sometimes to face, scalp and ear. Worsens with eye movements and may disturb sleep.
Redness
Photophobia
Watering
Visual loss
Globe tendernes

Gradual worsening over a few days
Unilateral usually but can be bilateral

Question 9

Signs

Answer 9

Anterior scleritis (90%)

NON-NECROTISING (75%) - hyperaemia of deeper and superficial blood vessels which do not blanche with phenylephrine, and do not move with cotton bud. sometimes anterior uveitis, corneal thinning and infiltrates may be present.
when inflammation resolving, scleral thinning means underlying choroidal pigment may show - blue/black hue to sclera.

60% diffuse, 40% nodular

-NECROTISING (15%) - most severe form - sometimes absence of pain and clinical signs (scleromalacia perforans), 3/4 have visual impairement. Avascular patches lead to scleral melting with ectasia and choroidal herniation.

Posterior scleritis (10%)
- inflammation posterior to ora seratta, eye may be white. Ophthalmoscopy may show exudative RD, macular and optic disc oedema. Sometimes no abnormalities detected