Opthalmology

Question 1

What is Scleritis?

Answer 1

• Inflammation of sclera
• Painful, destructive and vision threatening disorder
• 50% associated with systemic illness (RA, Granulomatosis w/ polyangitis)
• 90% anterior, 10% posterior (in relation to extra ocular muscles)
• Posterior and necrotising anterior are the most serious due to delayed recognition and close to the optic nerve

Question 2

H&E of Scleritis

Answer 2

• Severe boring pain, constant
  
  • Out of proportion to redness
  • Exacerbated on eye movement
• May have photophobia
• Diplopia and reduced vision (compression of optic nerve)
• Posterior scleritis may have less redness

Question 3

Investigations of Scleritis

Answer 3

• Slit-lamp
  
  • Anterior - scleral oedema + dilation deep episcleral vascular plexus
  • Posterior - choroidal thickening and retinal detachment
• B-scan ultrasonography to confirm scleral thickening
• CT/MRI to exclude orbital lesion

Question 4

Management of Scleritis

Answer 4

Mild-moderate (anterior)
- Mild symptoms - NSAIDs
- No response to NSAIDs or moderate - high dose prednisolone (gradually taper)

Severe (posterior/nercotising anterior)
- High dose prednisolone + rituximab (anti-CD20)
- If no response - cyclophosphamide (brief course due to high toxicity)
- If managed switch to azathioprine/methotrexate/mycophenolate mofetil

Stop all immunosuppressives 6-12 months after remission (12-24 if necrotising anterior)