Scleritis: Difference between revisions

Latest revision as of 21:54, 6 October 2019

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)

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
- Retinal detachment, optic disc edema

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

Nontraumatic
- Acute angle-closure glaucoma^
- Anterior uveitis
- Conjunctivitis
- Corneal erosion
- Corneal ulcer^
- Endophthalmitis^
- Episcleritis
- Herpes zoster ophthalmicus
- Inflamed pinguecula
- Inflamed pterygium
- Keratoconjunctivitis
- Keratoconus
- Nontraumatic iritis
- Scleritis^
- Subconjunctival hemorrhage
Orbital trauma

^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

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

Disposition

Urgent ophtho consult

References

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
-* Potentially blinding disorder
+*Potentially blinding disorder
-* 50% of cases associated with an underlying disorder
+*Sclera fuses with dura mater and arachnoid sheath of the opic nerve
-** RA
+**Reason why optic nerve edema and visual compromise are common complications
-** Wgener's
+*50% of cases associated with an underlying disorder:
-** IBD
+**[[Inflammatory bowel disease]]
-* Sclera fuses with the dura mater and arachnoid sheath of the opic nerve
+**[[Rheumatoid arthritis]]
-** Explains why optic nerve edema and visual compromise are common complications
+**[[Granulomatosis with polyangiitis]] (Wegners)
-==Diagnosis==
+==Clinical Features==
-* History
+[[File:Scleritis.png|thumb|Non-mobile inflammation of entire scleral thickness]]
-** Intense ocular pain that radiates to the face
+*Essential sign is scleral edema, usually accompanied by violaceous discoloration of the globe
-** Pain with EOM (the extraocular muscles insert into the sclera)
+*Intense [[eye pain|ocular pain]] that radiates to the face
-** Photophobia
+*Pain with EOM (extraocular muscles insert into the sclera)
-** Deep-red or purplish scleral hue
+*Photophobia
-* Physical
+*Globe tenderness to palpation
-** Essential sign is scleral edema, usually accompanied by violaceous discoloration of the globe
+*Episcleral vessel dilation
-** 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)
+===Posterior Scleritis===
-** Physical exam often benign
+*Posterior to the insertion of the extraocular muscles
-*** Inflammation may sometimes be seen at the extremes of gaze
+*Physical exam often benign
-** Pt c/o pain, pain upon EOM
+**Inflammation may sometimes be seen at the extremes of gaze
-** Involvement of the optic nerve and retina is common
+*Patient complains of pain, pain upon EOM
-*** Retinal detachment, optic disc edema
+*Involvement of the optic nerve and retina is common
+**[[Retinal detachment]], optic disc edema
-==Imaging==
+===Complications===
-Ultrasound and CT can show thickening of the sclera
+*Cornea (peripheral ulcerative keratitis → irreversible [[vision loss|loss of vision]])
+*Uveal tract (anterior [[uveitis]] seen in 40% - spillover of inflammation from the sclera)
+*Posterior segment ([[retinal detachment]], optic disc edema)
-==Treatment==
+==DifferentialDiagnosis==
-* Systemic therapy with NSAIDs, glucocorticoids, or other immunosuppressive drugs
+{{Unilateral red eye DDX}}
-* NSAIDs
-** Indomethacin 25-75mg PO TID
-==Dispo==
+==Evaluation==
-* Urgent ophto consult
+*Labs (to assess possible associated disease)
+**CBC
+**Chemistry
+**[[Urinalysis]] (evaluate for glomerulonephritis)
+**ESR, CRP
-==Complications==
+===Imaging===
-* Cornea
+*[[ocular ultrasound|Ultrasound]] and CT can show thickening of the sclera
-** Peripheral ulcerative keratitis > irreversible loss of vision
-* Uveal tract
+==Management==
-** Anterior uveitis seen in 40%
+*Systemic therapy with [[NSAIDs]], [[glucocorticoids]], or other immunosuppressive drugs
-*** Spillover of inflammation from the sclera
+*NSAIDs
-* Posterior segment
+**[[Indomethacin]] 25-75mg PO TID
-** Retinal detachment, optic disc edema
+==Disposition==
+*Urgent ophtho consult
 ==See Also==
-[[Episcleritis]]
+*[[Red eye]]
-==Source==
+==References==
-UpToDate
+<references/>
-[[Category:Ophtho]]
+[[Category:Ophthalmology]]