The clinical presentation of scleritis depends upon the anatomic site involved and the extent of inflammation. Patients often seek medical attention for severe, deep, boring pain that can be localized to the eye or generalized (66%), radiating along the trigeminal nerve distribution to the brow, temple, sinuses, and/or jaw [43, 45]. Pain is usually only temporarily relieved with analgesics and can be associated with malaise and weight loss, leading to misdiagnoses such as sinusitis, migraines, and brain tumour. Disten-tion of the nerve fibres secondary to scleral edema and necrosis of nerve endings are speculated to be responsible for pain that can be so severe as to awaken the patient. The most severe pain, often out of proportion to the extent of inflammation, is seen with progressive necrotizing scleri-tis, which can be a stark contrast to the absence of pain in scleromalacia perforans. The eye may feel tender to palpation due to the inflammation . However,tenderness is generally not experienced in necrotizing scleritis without inflammation. In contrast to scleritis, episcleritis is not associated with significant pain or tenderness.
Scleritis typically has a gradual onset of redness with increasing inflammation over several days . In contrast to the brighter redness of episcleritis, scleritis is usually a darker violaceous-red hue due to the depth of the congested vascular plexus. The extent of redness does not correlate with the severity of disease and may be absent in scleromalacia perforans.
Photophobia and lacrimation are non-specific symptoms sometimes associated with anterior scleritis, most often with necrotizing scleritis . Although approximately half of patients report tearing in posterior scleritis, photophobia is atypical. Conjunctival discharge is not a characteristic feature of scleritis and may suggest an infectious process.
Patients may experience an insidious onset of visual impairment, especially if the inflammatory process extends to other ocular tissues [22,34,40,42,45]. Loss of vision does not occur in cases of episcleritis.
Scleromalacia perforans is most notable for the potential lack of symptoms. Many patients often do not report any subjective symptoms, despite having significant signs of scleritis .
In addition to the symptoms described previously, posterior scleritis can present with less common symptoms of proptosis, lid edema, ptosis, and pain worsened with eye movement [3,22,43,45].
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