Scleritis (OP) Flashcards
Define scleritis.
Transmural inflammation of the sclera - inflammation of deep scleral vessels
Which demographics is scleritis common in?
- F>M
- 40-60 years
What other conditions are commonly found along with scleritis? (6)
Underlying systemic disorder or infection:
- commonly RA
- SLE
- IBD
- gout
- (granulomatosis with polyangiitis)
- (relapsing polychondritis)
What are the two types of scleritis?
- anterior scleritis (90%) - non-necrotising (75%) vs necrotising (15%)
- posterior scleritis
What is non-necrotising anterior scleritis (75%)?
- 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)
What is necrotising anterior scleritis (15%)?
- most severe form may be painless
- 75% eventually have visual impairment
- avascular patches –> scleral melting with ectasia and choroidal herniation
What is posterior scleritis (10%)?
- involves sclera posterior to ora serrata
- eye may be white
- ophthalmoscopy - exudative retinal detachment, macular oedema, optic disc oedema, may also be normal
What are the clinical features of scleritis? (5)
- pain - deep, aching, boring eye pain exacerbated by eye movement and palpation, may radiate to rest of face
- red eye
- photophobia
- lacrimation
- no discharge
When is eye pain in scleritis worse?
Worse at night, exacerbated by eye movement and palpation
How does scleritis present differently to episcleritis?
Episcleritis = painless red eye (inflammation more superficial)
Scleritis = painful red eye
What should you review in PMH in scleritis?
Systemic associations - connective tissue disorders etc:
- RA
- SLE
- IBD
- gout
- granulomatosis with polyangiitis
- relapsing polychondritis
What might you find on examination in scleritis? (3)
- 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)
What do we give to distinguish between scleritis and episcleritis?
Phenylephrine eye drops - if eye redness improves after –> episcleritis
What scans can we do in scleritis? (2)
- US - to see posterior scleritis
- orbital CT/MRI - to differentiate between orbital lesions
What else do we need to investigate in scleritis?
Systemic diseases e.g. RA, ANA (CRP/ESR)
What are some differentials for scleritis?
Acute red eye:
- episcleritis - usually self-limiting, managed with reassurance
- anterior uveitis - associated with ankylosing spondylitis, HLA-B27, Crohn’s, psoriatic arthritis
What are three major factors that distinguish scleritis vs episcleritis?
- severity of pain (no pain = episcleritis)
- pain on ocular movement
- non-blanching vessels
What do we need to do urgently if scleritis?
Urgent referral to ophthalmologist (threat to sight)
What analgesia do we give for scleritis?
Fluriprofen PO 100mg TDS generally improves Sx after 2 days
What is the management plan for scleritis?
- 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)
How do we manage acute scleritis?
Oral steroids
What is a complication of scleritis?
Perforation of globe
