Scleritis
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