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Scleritis

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Overview

Scleritis is the inflammation of the sclera (the white part of the eye) and may be associated with uveitis. It is a severe condition often requiring systemic treatment and must carefully be differentiated from scleritis as they present similarly, but have significantly different outcomes.

Epidemiology

  • Often seen in association with other inflammatory diseases such as rheumatoid arthritis
  • Sclerosis may be the first symptom of connective tissue disease

Risk Factors

Presentation

Unlike episcleritis, scleritis is classically painful, but the pain may still be mild. Features are:

  • Classically painful red eye – this may be mild
  • May be unilateral or bilateral
  • Eye watering
  • Photophobia
  • Gradual reduction in vision
  • Injected vessels do not move with gentle pressure, unlike in episcleritis
  • Phenylephrine eye drops do not improve redness, unlike in episcleritis

Differential Diagnoses

Anterior uveitis

  • Pain – may be worse with use i.e. reading something close by
  • Photophobia is more prominent
  • Ciliary flush may be present
  • Pupil margins may be irregular
  • Associated autoimmune disease/infection may be present

Episcleritis

  • Classically non-painful red eye but there may be mild pain
  • Watering and/or photophobia may be present but milder
  • Injected vessels are mobile and move with gentle pressure
  • Phenylephrine eye drops improve eye redness

Acute angle-closure glaucoma

  • Severe ocular pain/headache
  • Associated vomiting
  • Blurred vision and halos around light surfaces

Optic neuritis

  • There is no red eye
  • There is pain in eye movement
  • Colour desaturation may be seen – colours appear faded/washed-out

Investigations

Overview

  • Slit-lamp examination – shows inflammation in scleritis
  • Immediate (within 24 hours) referral to ophthalmology

Other investigations are generally carried out to assess for underlying causes such as:

  • FBC
  • U&Es
  • ESR:
    • Elevated in inflammation
  • CRP:
    • Elevated in infection/inflammation
  • Syphilis testing:
    • If suspected
  • Autoantibodies:
  • X-rays:
    • If chest pathology/spine or other bony pathology suspected 

Management

  • Immediate (within 24 hours) referral to ophthalmology
  • Management generally involves treating the underlying cause through the use of corticosteroids, immunosuppression, and antibiotics if indicated.

Patient Advice

  • Patients should be safety-netted on the symptoms of recurrence and be alerted about the possibility of episodes in the other eye

Complications

Prognosis

  • The prognosis depends on the presence of an underlying condition and the management of the said condition.
  • Early diagnosis and management of scleritis and effective management of any underlying conditions improve the prognosis.

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