Scleritis

Background

• Potentially blinding disorder
• 50% of cases associated with an underlying disorder
  • RA
  • Wgener's
  • IBD
• Sclera fuses with the dura mater and arachnoid sheath of the opic nerve
  • Explains why optic nerve edema and visual compromise are common complications

Diagnosis

• History
  • Intense ocular pain that radiates to the face
  • Pain with EOM (the extraocular muscles insert into the sclera)
  • Photophobia
  • Deep-red or purplish scleral hue
• Physical
  • Essential sign is scleral edema, usually accompanied by violaceous discoloration of the globe
  • The globe is tender to palpation
  • Episcleral vessel dilation
• Labs (to assess possible associated disease)
  • CBC
  • Chemistry
  • UA
    • Rule-out glomerulonephritis
  • ESR, CRP

• Posterior Scleritis (posterior to the insertion of the extraocular muscles)
  • Physical exam often benign
    • Inflammation may sometimes be seen at the extremes of gaze
  • Pt c/o pain, pain upon EOM
  • Involvement of the optic nerve and retina is common
    • Retinal detachment, optic disc edema

Imaging

Ultrasound and CT can show thickening of the sclera

Treatment

• Systemic therapy with NSAIDs, glucocorticoids, or other immunosuppressive drugs
• NSAIDs
  • Indomethacin 25-75mg PO TID�

Dispo

• Urgent ophto consult

Complications

• Cornea
  • Peripheral ulcerative keratitis > irreversible loss of vision
• Uveal tract
  • Anterior uveitis seen in 40%
    • Spillover of inflammation from the sclera
• Posterior segment
  • Retinal detachment, optic disc edema

Episcleritis

Background

• Abrupt onset of inflammation in the episclera
• 70% of cases occurs in women (usually young and middle-aged)
• Usually a benign, self-limited condition
• Usually not associated with an underlying disease

Diagnosis

• History
  • Abrupt onset of redness, irritation, and watering of the eye
  • Pain is unusual
  • Vision unaffected
  • 50% of cases are bilateral
• Physical
  • Vasodilatation of the superficial episcleral vessels

Work-Up

• Must distinguish from scleritis
  • Phenylephrine drops lead to transient resolution of episcleral redness permitting evaluation of the sclera
• Must distinguish from conjunctivitis
  • If the conjunctival injection is localized rather than diffuse, episcleritis is more likely

DDx

Scleritis Conjunctivitis Herpes Keratitis

Treatment

• Topical lubricants
  • Artificial tears q4-6hr

Disposition

• Refer to ophtho to reduce chance of misdiagnosis

Source

UpToDate

Scleritis

Background

• Potentially blinding disorder
• 50% of cases associated with an underlying disorder
• RA
• Wgener's
• IBD
• Sclera fuses with the dura mater and arachnoid sheath of the opic nerve
• Explains why optic nerve edema and visual compromise are common complications

Diagnosis

• History
• Intense ocular pain that radiates to the face
• Pain with EOM (the extraocular muscles insert into the sclera)
• Photophobia
• Deep-red or purplish scleral hue
• Physical
• Essential sign is scleral edema, usually accompanied by violaceous discoloration of the globe
• The globe is tender to palpation
• Episcleral vessel dilation
• Labs (to assess possible associated disease)
• CBC
• Chemistry
• UA
• Rule-out glomerulonephritis
• ESR, CRP

• Posterior Scleritis (posterior to the insertion of the extraocular muscles)
• Physical exam often benign
• Inflammation may sometimes be seen at the extremes of gaze
• Pt c/o pain, pain upon EOM
• Involvement of the optic nerve and retina is common
• Retinal detachment, optic disc edema

Imaging

• Ultrasound and CT can show thickening of the sclera

Treatment

• Systemic therapy with NSAIDs, glucocorticoids, or other immunosuppressive drugs
• NSAIDs
• Indomethacin 25-75mg PO TID

Dispo

• Urgent ophto consult

Complications

• Cornea
• Peripheral ulcerative keratitis > irreversible loss of vision
• Uveal tract
• Anterior uveitis seen in 40%
• Spillover of inflammation from the sclera
• Posterior segment
• Retinal detachment, optic disc edema

Episcleritis

Background

• Abrupt onset of inflammation in the episclera
• 70% of cases occurs in women (usually young and middle-aged)
• Usually a benign, self-limited condition
• Usually not associated with an underlying disease

Diagnosis

• History
• Abrupt onset of redness, irritation, and watering of the eye
• Pain is unusual
• Vision unaffected
• 50% of cases are bilateral
• Physical
• Vasodilatation of the superficial episcleral vessels

Work-Up

• Must distinguish from scleritis
• Phenylephrine drops lead to transient resolution of episcleral redness permitting evaluation of the sclera
• Must distinguish from conjunctivitis
• If the conjunctival injection is localized rather than diffuse, episcleritis is more likely

DDx

ScleritisConjunctivitisHerpes Keratitis ==Treatment==

• Topical lubricants
• Artificial tears q4-6hr

==Disposition==

• Refer to ophtho to reduce chance of misdiagnosis

Source

UpToDate