Scleritis

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Scleritis
Scleritis.png
Inflammation of entire thickness of the sclera
Specialty Ophthalmology, Optometry
Symptoms Eye redness, pain, photophobia, tearing, decrease in visual acuity
Usual onset30 - 60 years of age
Risk factors Female gender
Differential diagnosis Episcleritis
Treatment Non-steroidal anti-inflammatory drugs
Surgery (rarely needed)
FrequencyUncommon

Scleritis is a serious inflammatory disease that affects the white outer coating of the eye, known as the sclera. The disease is often contracted through association with other diseases of the body, such as granulomatosis with polyangiitis or rheumatoid arthritis. There are three types of scleritis: diffuse scleritis (the most common), nodular scleritis, and necrotizing scleritis (the most severe). Scleritis may be the first symptom of onset of connective tissue disease. [1]

Contents

Episcleritis is inflammation of the episclera, a less serious condition that seldom develops into scleritis. [2]

Signs and symptoms

Scleral translucency following recurrent scleritis. Recurrent scleritis.jpg
Scleral translucency following recurrent scleritis.

Symptoms of scleritis include: [3]

The pain of episcleritis is less severe than in scleritis. [4] In hyperemia, there is a visible increase in the blood flow to the sclera (hyperaemia), which accounts for the redness of the eye. Unlike in conjunctivitis, this redness will not move with gentle pressure to the conjunctiva.

Complications

Secondary keratitis or uveitis may occur with scleritis. [4] The most severe complications are associated with necrotizing scleritis.

Pathophysiology

Most of the time, scleritis is not caused by an infectious agent. [5] Histopathological changes are that of a chronic granulomatous disorder, characterized by fibrinoid necrosis, infiltration by polymorphonuclear cells, lymphocytes, plasma cells and macrophages. The granuloma is surrounded by multinucleated epitheloid giant cells and new vessels, some of which may show evidence of vasculitis.

Diagnosis

Scleritis is best detected by examining the sclera in daylight; retracting the lids helps determine the extent of involvement. Other aspects of the eye exam (i.e. visual acuity testing, slit lamp examination, etc.) may be normal. Scleritis may be differentiated from episcleritis by using phenylephrine eye drops, which causes blanching of the blood vessels in episcleritis, but not in scleritis. [4]

Ancillary tests CT scans, MRIs, and ultrasonographies can be helpful, but do not replace the physical examination.

Classification

Scleritis can be classified as anterior scleritis and posterior scleritis. Anterior scleritis is the most common variety, accounting for about 98% of the cases. It is of two types : Non-necrotising and necrotising. Non-necrotising scleritis is the most common, and is further classified into diffuse and nodular type based on morphology. Necrotising scleritis accounts for 13% of the cases. It can occur with or without inflammation.

Treatment

Medical

In mild to moderate cases of scleritis, non-steroidal anti-inflammatory drugs such as flurbiprofen, indomethacin or ibuprofen may be prescribed for pain relief. [6] Systemic corticosteroids like prednisolone may be used if NSAIDs are inappropriate or scleritis is posterior or necrotizing. [7] Periocular steroid injections may be used in non-necrotizing scleritis, but it is contraindicated in necrotizing disease. [7] If disease control is inadequate with steroids alone, immunosuppressives (Eg: cyclophosphamide, azathioprine, methotrexate) and/or immunomodulators may be considered for treatment. [7] In infective scleritis, if infective agent is identified, topical or systemic antibiotics may be prescribed. [7] [8]

Surgical intervention

Surgery may be indicated if scleral perforation or excessive scleral thinning is present. [6] Bandage contact lens or corneal glue may be used to repair damaged corneal tissue in the eye and preserve the patient's vision. [6] If not treated, scleritis can cause blindness.

Epidemiology

Scleritis is not a common disease, although the exact prevalence and incidence are unknown. It is somewhat more common in women, and is most common in the fourth to sixth decades of life. [9]

Related Research Articles

<span class="mw-page-title-main">Conjunctivitis</span> Inflammation of the eye

Conjunctivitis, also known as pink eye or Madras eye, is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid. It makes the eye appear pink or reddish. Pain, burning, scratchiness, or itchiness may occur. The affected eye may have increased tears or be "stuck shut" in the morning. Swelling of the white part of the eye may also occur. Itching is more common in cases due to allergies. Conjunctivitis can affect one or both eyes.

<span class="mw-page-title-main">Sclera</span> White part of an eyeball

The sclera, also known as the white of the eye or, in older literature, as the tunica albuginea oculi, is the opaque, fibrous, protective outer layer of the eye containing mainly collagen and some crucial elastic fiber.

<span class="mw-page-title-main">Cornea</span> Transparent front layer of the eye

The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Along with the anterior chamber and lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical power. In humans, the refractive power of the cornea is approximately 43 dioptres. The cornea can be reshaped by surgical procedures such as LASIK.

<span class="mw-page-title-main">Pterygium (eye)</span> Pinkish, triangular tissue growth on the cornea of the eye

A pterygium of the eye is a pinkish, roughly triangular tissue growth of the conjunctiva onto the cornea of the eye. It typically starts on the cornea near the nose. It may slowly grow but rarely grows so large that it covers the pupil and impairs vision. Often both eyes are involved.

<span class="mw-page-title-main">Eye surgery</span> Surgery performed on the eye or its adnexa

Eye surgery, also known as ophthalmic surgery or ocular surgery, is surgery performed on the eye or its adnexa. Eye surgery is part of ophthalmology and is performed by an ophthalmologist or eye surgeon. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems.

<span class="mw-page-title-main">Prednisolone</span> Corticosteroid medication

Prednisolone is a corticosteroid, a steroid hormone used to treat certain types of allergies, inflammatory conditions, autoimmune disorders, and cancers. Some of these conditions include adrenocortical insufficiency, high blood calcium, rheumatoid arthritis, dermatitis, eye inflammation, asthma, and multiple sclerosis. It can be taken by mouth, injected into a vein, used topically as a skin cream, or as eye drops. It differs from the similarly named prednisone in having a hydroxyl at the 11th carbon instead of a ketone.

<span class="mw-page-title-main">Red eye (medicine)</span> Eye that appears red due to illness or injury

A red eye is an eye that appears red due to illness or injury. It is usually injection and prominence of the superficial blood vessels of the conjunctiva, which may be caused by disorders of these or adjacent structures. Conjunctivitis and subconjunctival hemorrhage are two of the less serious but more common causes.

<span class="mw-page-title-main">Fuchs' dystrophy</span> Medical condition

Fuchs dystrophy, also referred to as Fuchs endothelial corneal dystrophy (FECD) and Fuchs endothelial dystrophy (FED), is a slowly progressing corneal dystrophy that usually affects both eyes and is slightly more common in women than in men. Although early signs of Fuchs dystrophy are sometimes seen in people in their 30s and 40s, the disease rarely affects vision until people reach their 50s and 60s.

<span class="mw-page-title-main">Scleral lens</span> Large contact lens resting on the sclera, creating a tear-filled vault over the cornea

A scleral lens, also known as a scleral contact lens, is a large contact lens that rests on the sclera and creates a tear-filled vault over the cornea. Scleral lenses are designed to treat a variety of eye conditions, many of which do not respond to other forms of treatment.

Granulomatous meningoencephalitis (GME) is an inflammatory disease of the central nervous system (CNS) of dogs and, rarely, cats. It is a form of meningoencephalitis. GME is likely second only to encephalitis caused by canine distemper virus as the most common cause of inflammatory disease of the canine CNS. The disease is more common in female dogs of young and middle age. It has a rapid onset. The lesions of GME exist mainly in the white matter of the cerebrum, brainstem, cerebellum, and spinal cord. The cause is only known to be noninfectious and is considered at this time to be idiopathic. Because lesions resemble those seen in allergic meningoencephalitis, GME is thought to have an immune-mediated cause, but it is also thought that the disease may be based on an abnormal response to an infectious agent. One study searched for viral DNA from canine herpesvirus, canine adenovirus, and canine parvovirus in brain tissue from dogs with GME, necrotizing meningoencephalitis, and necrotizing leukoencephalitis, but failed to find any.

<span class="mw-page-title-main">Corneal ulcers in animals</span> Veterinary inflammatory condition of the cornea

A corneal ulcer, or ulcerative keratitis, is an inflammatory condition of the cornea involving loss of its outer layer. It is very common in dogs and is sometimes seen in cats. In veterinary medicine, the term corneal ulcer is a generic name for any condition involving the loss of the outer layer of the cornea, and as such is used to describe conditions with both inflammatory and traumatic causes.

<span class="mw-page-title-main">Episcleritis</span> Medical condition

Episcleritis is a benign, self-limiting inflammatory disease affecting part of the eye called the episclera. The episclera is a thin layer of tissue that lies between the conjunctiva and the connective tissue layer that forms the white of the eye (sclera). Episcleritis is a common condition, and is characterized by the abrupt onset of painless eye redness.

<span class="mw-page-title-main">Pinguecula</span> Medical condition

A pinguecula is a common type of conjunctival stromal degeneration in the eye. It appears as an elevated yellow-white plaque in the bulbar conjunctiva near the limbus. Calcification may also be seen occasionally.

<span class="mw-page-title-main">Corneal neovascularization</span> Medical condition

Corneal neovascularization (CNV) is the in-growth of new blood vessels from the pericorneal plexus into avascular corneal tissue as a result of oxygen deprivation. Maintaining avascularity of the corneal stroma is an important aspect of healthy corneal physiology as it is required for corneal transparency and optimal vision. A decrease in corneal transparency causes visual acuity deterioration. Corneal tissue is avascular in nature and the presence of vascularization, which can be deep or superficial, is always pathologically related.

<span class="mw-page-title-main">Corneal ulcer</span> Inflammation of the cornea of the eye due to trauma or infection

Corneal ulcer, also called keratitis, is an inflammatory or, more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and in farming. In developing countries, children afflicted by vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes persisting throughout life. In ophthalmology, a corneal ulcer usually refers to having an infection, while the term corneal abrasion refers more to a scratch injury.

<span class="mw-page-title-main">Conjunctivochalasis</span> Excess folds of the conjunctiva of the eye

Conjunctivochalasis, also known as mechanical dry eye (MDE), is a common eye surface condition characterized by the presence of excess folds of the conjunctiva located between the globe of the eye and the eyelid margin.

<span class="mw-page-title-main">Herpes simplex keratitis</span> Medical condition

Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea.

Open-globe injuries are full-thickness eye-wall wounds requiring urgent diagnosis and treatment.

Mooren's ulcer is a rare idiopathic ocular disorder that may lead to blindness due to progressive destruction of the peripheral cornea. Although the etiology of Mooren's ulcer is poorly understood, recent evidence suggests that the pathogenesis of this disease appears to be the result of an autoimmune process directed against molecules expressed in the corneal stroma.

Peripheral Ulcerative Keratitis (PUK) is a group of destructive inflammatory diseases involving the peripheral cornea in human eyes. The symptoms of PUK include pain, redness of the eyeball, photophobia, and decreased vision accompanied by distinctive signs of crescent-shaped damage of the cornea. The causes of this disease are broad, ranging from injuries, contamination of contact lenses, to association with other systemic conditions. PUK is associated with different ocular and systemic diseases. Mooren's ulcer is a common form of PUK. The majority of PUK is mediated by local or systemic immunological processes, which can lead to inflammation and eventually tissue damage. Standard PUK diagnostic test involves reviewing the medical history and a completing physical examinations. Two major treatments are the use of medications such as corticosteroids or other immunosuppressive agents and surgical resection of the conjunctiva. The prognosis of PUK is unclear with one study providing potential complications. PUK is a rare condition with an estimated incidence of 3 per million annually.

References

  1. "Scleritis". WebMD, LLC. Medscape. Retrieved 27 November 2012.
  2. "Episcleritis: MedlinePlus Medical Encyclopedia". Bethesda, MD: United States National Library of Medicine . Retrieved 20 June 2010.
  3. Vorvick, Linda J. (July 28, 2010). "Scleritis". PubMed Health. United States National Library of Medicine . Retrieved July 6, 2011.
  4. 1 2 3 Goldman, Lee (2011). Goldman's Cecil Medicine (24th ed.). Philadelphia: Elsevier Saunders. p. 2440. ISBN   978-1437727883.
  5. Yanoff, Myron; Jay S. Duker (2008). Ophthalmology (3rd ed.). Edinburgh: Mosby. pp. 255–261. ISBN   978-0323057516.
  6. 1 2 3 "Scleritis". EyeWiki. American Academy of Ophthalmology. 23 July 2024.
  7. 1 2 3 4 Salmon, John F. (2020). "Episclera and sclera". Kanski's clinical ophthalmology: a systematic approach (9th ed.). Edinburgh: Elsevier. ISBN   978-0-7020-7713-5. OCLC   1131846767.
  8. Ramanjit, Sihota; Radhika, Tandon (2015). Parsons' diseases of the eye (22nd ed.). New Delhi, India: Elsevier. ISBN   978-81-312-3819-6. OCLC   905915528.
  9. Maite Sainz de la Maza (Feb 15, 2012). The sclera (2nd ed.). New York: Springer. p. 102. ISBN   978-1441965011.