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)


==Clinical Features==
[[File:Scleritis.png|thumb|Non-mobile inflammation of entire scleral thickness]]
*Essential sign is scleral edema, usually accompanied by violaceous discoloration of the globe
*Intense [[eye pain|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 [[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)


===Background===
==DifferentialDiagnosis==
 
{{Unilateral red eye DDX}}
 
* 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
=== ===


==Evaluation==
*Labs (to assess possible associated disease)
**CBC
**Chemistry
**[[Urinalysis]] (evaluate for glomerulonephritis)
**ESR, CRP


===Imaging===
===Imaging===
*[[ocular ultrasound|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


* Ultrasound and CT can show thickening of the sclera
==Disposition==
*Urgent ophtho consult
 
===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
 


==See Also==
*[[Red eye]]


==References==
<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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