Core Messages

• Scleritis is highly associated with potentially devastating ocular complications and serious systemic diseases

• Necrotizing scleritis has the highest association with systemic disease and is frequently the first manifestation of a systemic condition

• Scleromalacia perforans is most commonly associated with long-standing rheumatoid arthritis and may present without any symptoms

• Scleritis in predisposed individuals may occur after ocular trauma, including ocular surgery

• Scleritis can develop due to an infectious aetiology and requires early recognition and treatment

• Scleritis should be distinguished from episcleritis, as it represents different clinical entities with very contrasting clinical presentations, disease courses, treatments, and prognoses. Lack of vasoconstriction with phenylephrine is a helpful diagnostic test

• Scleritis is a clinical diagnosis and most commonly presents with severe eye pain

• The clinical presentation of scleritis depends on the anatomic site involved and the extent of inflammation, forming the basis for the classification of scleritis (Table 5.1)

• Ocular complications of scleritis include loss of vision, keratitis, progression of cataract, uveitis, glaucoma, scleral thinning and perforation, staphyloma, retinal detach-ment,and choroidal detachment

• Evaluation for associated systemic illness must be included in the history, physical exam, and diagnostic testing. Referral to an internist or rheumatologist can be of great assistance

• Ancillary diagnostic testing may be helpful in the diagnosis and management, especially in cases of posterior scleritis

• Scleritis is medically managed with systemic non-steroidal anti-inflammatory agents, corticosteroids,and steroid-sparing immunosuppressants in a stepwise manner

• Five to 10% of cases require surgical management and have the greatest success when the inflammation is suppressed medically

• The classification of scleritis by subtypes offers prognostic information and serves as a guideline for therapy

• Diffuse anterior scleritis is the most benign form, nodular scleritis has an intermediate prognosis, and necrotizing scleritis has the worst prognosis in terms of ocular and systemic morbidity

• Early diagnosis and treatment of scleritis is important in preventing and diminishing ocular and systemic morbidity

Table 5.1. Classification of scleritis

Prevalence

Watson

Foster

I. Anterior scleritis

98%

94%

a) Diffuse

40%

45%

b) Nodular

44%

23%

c) Necrotizing

14%

26%

i) With

inflammation

(10%)

(23%)

ii) Without

inflammation

= scleromalacia

perforans

(4%)

(3%)

II. Posterior scleritis

2%

6%

Table 5.2. Scleritis vs. episcleritis

Episcleritis

Scleritis

Main symptom

Redness

Severe,

radiating

pain

Redness

Bright red

Bluish red

Maximum

Superficial

Deep

Vascular

Episcleral

Episcleral

Congestion

Vessels

Vessels

Tenderness

Rare

+

Scleral thinning

Rare

+

Vision affected

Rare

+

Intraocular

involvement

Rare

+

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