Scleritis & Episcleritis

Question 1

What is scleritis?

Answer 1

Inflammation of the sclera

Question 2

What is the sclera?

Answer 2

The outer layer of connective tissue surrounding most of the eye. It forms the visible white part of the eye.

Question 3

What is the most severe type of scleritis?

Answer 3

Necrotising scleritis - can lead to perforation of the sclera.

Question 4

Causes of scleritis?

Answer 4

1) Idiopathic

2) Underlying systemic inflammatory condition

3) Infection e.g. Pseudomonas or Staphy aureus

Question 5

There is an associated systemic condition in around 50% of patients presenting with scleritis.

What are the 2 most common conditions?

Answer 5

1) RA

2) Vasculitis ( particularly granulomatosis with polyangiitis)

Question 6

Presentation of scleritis?

Answer 6

• Red eye
• Painful (in comparison to episcleritis)
• Congested vessels
• Pain with eye movement
• Photophobia
• Epiphora (excessive tear production)
• Reduced visual acuity
• Tenderness to palpation of the eye

Question 7

Investigations in scleritis?

Answer 7

1) Refer for urgent assessment and management by an ophthalmologist.

2) Assess for underlying systemic condition (e.g., RA or vasculitis).

Question 8

Mx of scleritis?

Answer 8

1) NSAIDs

2) Steroids (topial or systemic)

3) Immunosuppression appropriate to the underlying systemic condition (e.g., methotrexate in RA)

4) Antimicrobial if infection

Question 9

What is episcleritis?

Answer 9

Episcleritis involves benign and self-limiting inflammation of the episclera.

Question 10

What is the episclera?

Answer 10

The outermost layer of the sclera, just below the conjunctiva.

Question 11

What is episcleritis usually associated with?

Answer 11

Inflammatory disorders, such as RA arthritis and IBD.

It is not usually caused by infection.

Question 12

Presentation of episcleritis?

Answer 12

• Acute onset, unilateral
• Localised or diffuse redness (often a patch of redness in the lateral sclera)
• Often painless
• Dilated episcleral vessels

Importantly, there is no photophobia or discharge and normal visual acuity –> these symptoms suggest scleritis.

Question 13

What medication can differentiate between episcleritis & scleritis?

Answer 13

Applying phenylephrine eye drops.

It will cause blanching of the episcleral vessels, causing the redness to disappear. It will not affect scleral vessels and will not impact the redness in scleritis.

Question 14

Mx of episcleritis?

Answer 14

Episcleritis is usually self-limiting and will resolve in 1-2 weeks. In mild cases, no treatment is necessary.

Symptoms may be relieved with analgesia (e.g., ibuprofen) and lubricating eye drops.
More severe cases may be treated with steroid eye drops.