Scleritis (OP)

Question 1

Define scleritis.

Answer 1

Transmural inflammation of the sclera - inflammation of deep scleral vessels

Question 2

Which demographics is scleritis common in?

Answer 2

• F>M
• 40-60 years

Question 3

What other conditions are commonly found along with scleritis? (6)

Answer 3

Underlying systemic disorder or infection:

• commonly RA
• SLE
• IBD
• gout
• (granulomatosis with polyangiitis)
• (relapsing polychondritis)

Question 4

What are the two types of scleritis?

Answer 4

• anterior scleritis (90%) - non-necrotising (75%) vs necrotising (15%)
• posterior scleritis

Question 5

What is non-necrotising anterior scleritis (75%)?

Answer 5

• usually unilateral
• hyperaemia of superficial and deep episcleral vessels
• does not blanch with vasoconstrictors
• anterior uveitis may be present
• tenderness of globe
• when inflammation resolved, choroidal pigment may show through thinned sclera as a blue/black colouration
• approximately 60% are diffuse and 40% nodular (nodule cannot be moved over underlying tissue)

Question 6

What is necrotising anterior scleritis (15%)?

Answer 6

• most severe form may be painless
• 75% eventually have visual impairment
• avascular patches –> scleral melting with ectasia and choroidal herniation

Question 7

What is posterior scleritis (10%)?

Answer 7

• involves sclera posterior to ora serrata
• eye may be white
• ophthalmoscopy - exudative retinal detachment, macular oedema, optic disc oedema, may also be normal

Question 8

What are the clinical features of scleritis? (5)

Answer 8

• pain - deep, aching, boring eye pain exacerbated by eye movement and palpation, may radiate to rest of face
• red eye
• photophobia
• lacrimation
• no discharge

Question 9

When is eye pain in scleritis worse?

Answer 9

Worse at night, exacerbated by eye movement and palpation

Question 10

How does scleritis present differently to episcleritis?

Answer 10

Episcleritis = painless red eye (inflammation more superficial)

Scleritis = painful red eye

Question 11

What should you review in PMH in scleritis?

Answer 11

Systemic associations - connective tissue disorders etc:

• RA
• SLE
• IBD
• gout
• granulomatosis with polyangiitis
• relapsing polychondritis

Question 12

What might you find on examination in scleritis? (3)

Answer 12

• deep scleral vessel engorgement and pain on ocular palpation
• no fluorescein stain
• visual acuity and pupillary reactions may be abnormal (depending on position of scleritis on globe)

Question 13

What do we give to distinguish between scleritis and episcleritis?

Answer 13

Phenylephrine eye drops - if eye redness improves after –> episcleritis

Question 14

What scans can we do in scleritis? (2)

Answer 14

• US - to see posterior scleritis
• orbital CT/MRI - to differentiate between orbital lesions

Question 15

What else do we need to investigate in scleritis?

Answer 15

Systemic diseases e.g. RA, ANA (CRP/ESR)

Question 16

What are some differentials for scleritis?

Answer 16

Acute red eye:

• episcleritis - usually self-limiting, managed with reassurance
• anterior uveitis - associated with ankylosing spondylitis, HLA-B27, Crohn’s, psoriatic arthritis

Question 17

What are three major factors that distinguish scleritis vs episcleritis?

Answer 17

1. severity of pain (no pain = episcleritis)
2. pain on ocular movement
3. non-blanching vessels

Question 18

What do we need to do urgently if scleritis?

Answer 18

Urgent referral to ophthalmologist (threat to sight)

Question 19

What analgesia do we give for scleritis?

Answer 19

Fluriprofen PO 100mg TDS generally improves Sx after 2 days

Question 20

What is the management plan for scleritis?

Answer 20

• mild-mod disease: NSAIDs
• if they do not work: systemic glucocorticoids
• if unresponsive to steroids: systemic immunosuppressive therapy (azathioprine, methotrexate, biologics e.g. TNF-a)

Question 21

How do we manage acute scleritis?

Answer 21

Oral steroids

Question 22

What is a complication of scleritis?

Answer 22

Perforation of globe