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Thursday, December 23, 2010

Scleritis

  SIGNS AND SYMPTOMS
Unlike the mild sensitivity of episcleritis, true scleritis presents with severe, boring ocular pain which may also involve the adjacent head and facial regions. The scleral vessels are significantly dilated, as are the overlying vessels of the episclera and bulbar conjunctiva. The affected eye may be so injected in some cases that the eye actually takes on a deep red, almost purple, hue. This presentation may be sectoral or diffuse.

Patients typically report a gradual onset of the pain and redness, with associated photophobia, tearing and decreased vision. Slip lamp evaluation may reveal scleral nodules (nodular scleritis), peripheral keratitis and secondary uveitis in some instances. In severe cases of necrotizing scleritis, the sclera may become transparent due to chronic inflammation, revealing the underlying dark blue of the choroid.


PATHOPHYSIOLOGY
Scleritis is a primary inflammation of the sclera, which is often (over 50 percent of cases) associated with systemic disease. Among the most common related disorders are rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, polyarteritis nodosa, Wegener's granulomatosis, herpes zoster virus, gout and syphilis.

Unlike episcleritis, the inflammation characteristic of scleritis has the capacity to spread to other ocular tissues of the anterior segment and/or posterior segment. Consequently, if you do not begin treatment of scleritis immediately, the condition poses the risk of severe visual compromise in the form of cataracts, secondary glaucoma, choroidal or exudative retinal detachment or optic atrophy.

MANAGEMENT
Topical medications alone are generally insufficient in managing scleritis. In addition to cycloplegia (scopolamine 0.25% BID/QID or atropine 1% BID) and a topical steroid, scleritis indicates a systemic anti-inflammatory agents as well. Treat moderate sectoral or diffuse anterior scleritis with oral NSAIDs (e.g., ibuprofen 600mg QID or indomethacin 25mg TID).

If the inflammation is severe or necrotizing, or if non-steroidals alone fail to suppress the inflammation, use a systemic steroid such as oral prednisone 80mg QD for two to three days, then slowly taper to 10 to 20mg daily. It may also be necessary for patients to receive a small maintenance dose for up to one month to control the condition. In rare cases, the patient may require immunosuppressive agents and should be managed by a rheumatologist.

CLINICAL PEARLS

Treated improperly, scleritis can render a great deal of damage to the affected eye.
Be sure to distinguish between this disorder and the less threatening episcleritis.
Occasionally, an atypical presentation of necrotizing scleritis without inflammation may occur; this is known as scleromalacia perforans. In this presentation, the sclera thins significantly in discrete areas, allowing for local outpouchings of the underlying choroid. There is no recognized treatment for this condition.
In all cases of scleritis, always consider the underlying cause to be systemic disease until proven otherwise. Refer patients for a comprehensive medical evaluation, including serology and radiology studies where appropriate. Specific tests may include: complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA), HLA-B27, rheumatoid factor (RF), angiotensin-converting enzyme (ACE), fluorescent treponemal antibody absorption (FTA-ABS), lyme titer, chest X-ray and sacroiliac joint films.

3 comments:

  1. Hello there! I'm glad to stop by your site and know more about scleritis. Keep it up! This is a good read. I will be looking forward to visit your page again and for your other posts as well. Thank you for sharing your thoughts about scleritis.
    One of the symptoms of scleritis is severe ocular pain, which may radiate to the temple or jaw. The pain is often decribed as deep or boring.
    Scleritis. Inflammation of sclera. What exactly is the sclera? The sclera is the white envelope-wall of the eyeball. It is taken for granted by patients and physicians alike, enjoying relative freedom from major, vision-robbing mischief. It is comprised of collagen, one of the forms of so called "connective tissue," and it comprises 4/5 of the tough outer wall of the eyeball; the other 1/5 is comprised of the crystal clear, watch glass structure in the very front of the eye through which we see, the cornea.

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  2. Very nice post, thanks for sharing the information. Keep up the good work.

    scleritis

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  3. Hi there! great stuff here, I'm glad that I drop by your page and found this very interesting. Thanks for posting. Hoping to read something like this in the future! Keep it up!

    Scleritis may occur as a result of various stimuli, the most famous of which is rheumatoid arthritis. But many of the so called connective tissue diseases or collagen vascular diseases may have scleritis as part of their disease spectrum. Indeed, inflammation of the sclera can sometimes be a presenting manifestation of a potentially very serious systemic disease. Sometimes inflammation in the eye will precede extraocular (outside the eye) manifestations of a serious systemic disease by many months or even a few years. This is but one of the many reasons why it is so critical for patients to regularly visit with a physician trained in ophthalmology: an ophthalmologist.

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