Scleritis

Introduction 2

The sclera is the outermost protective surface of the eye and consists of about 83% of the total surface area. The white part of the eye is the sclera and helps with eye protection and movement.

Inflammation of the sclera is known as scleritis. Pain is the most prominent symptom of scleritis. It is a chronic and potentially blinding condition if left untreated. Scleritis may occur in isolation or as the manifestation of other underlying diseases, such as autoimmune disorders. Early diagnosis and management of scleritis are essential to prevent damage to the eye. 

Scleritis is an overall uncommon disease. Women between 40 to 60 years old develop scleritis more often than men. Its prognosis depends on the disease severity and ranges from self-limited to vision-threatening. Patients with symptoms of scleritis should be evaluated by an ophthalmologist promptly for proper management and treatment.

Types of scleritis 2

Scleritis may be classified as follows:

• Anterior scleritis

• It may be further classified into diffuse, nodular, or necrotizing scleritis. The most common clinical form is diffuse scleritis. Necrotizing is a less frequent and more serious condition.  

• Posterior scleritis 

• It is characterized by the flattening of the posterior sclera and the thickening of the posterior surface. It is difficult to diagnose because of its posterior location. 

Causes of scleritis 2,1

The human body consists of an interconnected system of multiple organs, tissues, and cells that work together to ward off bacteria and viruses. Sometimes, due to unknown reasons, the body mistakenly attacks its own cells by considering them foreign invaders. Scleritis may occur due to an autoimmune phenomenon. 

Scleritis may happen in isolation or in association with other autoimmune diseases, including the following:

• Rheumatoid arthritis
• Systemic lupus erythematosus
• Reactive arthritis 
• Sjogren's syndrome 
• Inflammatory bowel disease
• Dermatomyositis
• Polymyositis
• Ankylosing spondylitis
• Vasculitis
• Drug reactions
• Chemical injuries
• Atopy

Signs and symptoms of scleritis 1,2

Scleritis has varying signs and symptoms depending on the type and involvement of tissues. It may be associated with the following:

• Pain is the most pronounced symptom of scleritis. This pain can awaken the patient at night from sleep. It can be exacerbated with eye movement and involve one side of the face.
• Tenderness
• Blurring and decrease in vision 
• Excessive tear formation
• Photosensitivity
• Redness of the affected part of the eye

Unfortunately, when patients present in the emergency room for scleritis, they usually get inappropriate treatment e.g topical antibiotics. This practice can prolong the disease course. 

Diagnosis of scleritis 1

Your eye doctor or healthcare practitioner will take your history and do a complete ocular examination to make the diagnosis. The workup of scleritis may involve the following points:

• Taking a complete history:
• symptoms 
• any previous ocular diseases
• any previous injury
• history of surgery
• history of vascular disease
• history of drug intake
• questions regarding other systems related to autoimmune disorders 
• Slit lamp examination 

• Laboratory investigations (blood work)

• Rheumatoid factor
• Antinuclear antibodies
• HLA typing
• ESR
• IgE count
• Uric acid level
• Skin prick test
• Serology for infections

• Imaging studies

• Joint radiography
• Chest radiography to rule out sarcoidosis or atopy
• Ocular ultrasonography
• Ocular CT scan
• Ocular MRI

Management of scleritis 1

The treatment of scleritis depends on the treatment of the underlying disease, and always requires systemic therapy. During the management of scleritis, a combination of systemic and ocular therapy is used.  The use of combination therapy reduces the risk of recuerrence and complications.

• Topical corticosteroids
• Systemic corticosteroids 
• Systemic NSAIDs
• Immunomodulatory drugs
• Antibiotics in case of underlying infections
• Tectonic surgical procedures may be used rarely
• Scleral grafting 

Patients with scleritis require long-term monitoring of medication side effects, their dosage, and  treatment effect. At every follow-up, the patient will be monitored with a slit lamp examination.

Complications

Early diagnosis and treatment of scleritis are necessary for the prevention of complications. The possible complications of scleritis are the following:

• Keratitis
• Uveitis
• Cataract formation
• Glaucoma
• Macular edema
• Retinal detachment

References 

1. Roque, M. R., MD. (2022, November 15). Scleritis Clinical Presentation: History, Causes, Physical Examination. https://emedicine.medscape.com/article/1228324-clinical
2. What Is Scleritis? (2022, September 9). American Academy of Ophthalmology. https://www.aao.org/eye-health/diseases/what-is-scleritis

Author

Eye Surgeons Associates Drs. Zuhair H. Peracha, Manal H. Peracha-Riyaz, Eric Zuckerman, Matthew Pieters, and Leila Siblani are dedicated to excellence in eye care and service. We utilize the latest treatment methods and procedures, including routine eye care, cataract surgery, glaucoma treatment, retinal disease management, diabetic eye treatment, and eyelid surgery.