Scleritis

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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