Scleritis: Difference between revisions

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==Scleritis==
==Background==
*Potentially blinding disorder
*Sclera fuses with dura mater and arachnoid sheath of the opic nerve
**Reason why optic nerve edema and visual compromise are common complications
*50% of cases associated with an underlying disorder:
**[[Inflammatory bowel disease]]
**[[Rheumatoid arthritis]]
**[[Granulomatosis with polyangiitis]] (Wegners)


===Background===
==Clinical Features==
* Potentially blinding disorder
[[File:Scleritis.png|thumb|Non-mobile inflammation of entire scleral thickness]]
* 50% of cases associated with an underlying disorder
*Essential sign is scleral edema, usually accompanied by violaceous discoloration of the globe
** RA
*Intense [[eye pain|ocular pain]] that radiates to the face
** Wgener's
*Pain with EOM (extraocular muscles insert into the sclera)
** IBD
*Photophobia
* Sclera fuses with the dura mater and arachnoid sheath of the opic nerve
*Globe tenderness to palpation
** Explains why optic nerve edema and visual compromise are common complications
*Episcleral vessel dilation


===Diagnosis===
===Posterior Scleritis===
* History
*Posterior to the insertion of the extraocular muscles
** Intense ocular pain that radiates to the face
*Physical exam often benign
** Pain with EOM (the extraocular muscles insert into the sclera)
**Inflammation may sometimes be seen at the extremes of gaze
** Photophobia
*Patient complains of pain, pain upon EOM
** Deep-red or purplish scleral hue
*Involvement of the optic nerve and retina is common
* Physical
**[[Retinal detachment]], optic disc edema
** 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===
===Complications===
* Cornea
*Cornea (peripheral ulcerative keratitis → irreversible [[vision loss|loss of vision]])
** Peripheral ulcerative keratitis > irreversible loss of vision
*Uveal tract (anterior [[uveitis]] seen in 40% - spillover of inflammation from the sclera)
* Uveal tract
*Posterior segment ([[retinal detachment]], optic disc edema)
** Anterior uveitis seen in 40%
*** Spillover of inflammation from the sclera
* Posterior segment
** Retinal detachment, optic disc edema


==Episcleritis==
==DifferentialDiagnosis==
{{Unilateral red eye DDX}}


===Background===
==Evaluation==
* Abrupt onset of inflammation in the episclera
*Labs (to assess possible associated disease)
* 70% of cases occurs in women (usually young and middle-aged)
**CBC
* Usually a benign, self-limited condition
**Chemistry
* Usually not associated with an underlying disease
**[[Urinalysis]] (evaluate for glomerulonephritis)
**ESR, CRP


==Diagnosis==
===Imaging===
* History
*[[ocular ultrasound|Ultrasound]] and CT can show thickening of the sclera
** 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==
==Management==
* Must distinguish from scleritis
*Systemic therapy with [[NSAIDs]], [[glucocorticoids]], or other immunosuppressive drugs
** Phenylephrine drops lead to transient resolution of episcleral redness permitting evaluation of the sclera
*NSAIDs
* Must distinguish from conjunctivitis
**[[Indomethacin]] 25-75mg PO TID
** If the conjunctival injection is localized rather than diffuse, episcleritis is more likely


==DDx==
==Disposition==
#Scleritis
*Urgent ophtho consult
#Conjunctivitis
#Herpes Keratitis
 
==Treatment==
# Topical lubricants
## Artificial tears q4-6hr


==Disposition==
==See Also==
Refer to ophtho to reduce chance of misdiagnosis
*[[Red eye]]


==Source==
==References==
UpToDate
<references/>


[[Category:Ophtho]]
[[Category:Ophthalmology]]

Latest revision as of 21:54, 6 October 2019

Background

Clinical Features

Non-mobile inflammation of entire scleral thickness
  • Essential sign is scleral edema, usually accompanied by violaceous discoloration of the globe
  • Intense ocular pain that radiates to the face
  • Pain with EOM (extraocular muscles insert into the sclera)
  • Photophobia
  • Globe tenderness to palpation
  • Episcleral vessel dilation

Posterior Scleritis

  • Posterior to the insertion of the extraocular muscles
  • Physical exam often benign
    • Inflammation may sometimes be seen at the extremes of gaze
  • Patient complains of pain, pain upon EOM
  • Involvement of the optic nerve and retina is common

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)

DifferentialDiagnosis

Unilateral red eye

^Emergent diagnoses ^^Critical diagnoses

Evaluation

  • Labs (to assess possible associated disease)
    • CBC
    • Chemistry
    • Urinalysis (evaluate for glomerulonephritis)
    • ESR, CRP

Imaging

  • Ultrasound and CT can show thickening of the sclera

Management

Disposition

  • Urgent ophtho consult

See Also

References

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