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Ocular Immunology and Inflammation

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Imaging of the Sclera in Patients with Scleritis and

Episcleritis using Anterior Segment Optical Coherence
Tomography
a a a
S. Axmann MD , A. Ebneter MD, PhD & M. S. Zinkernagel MD, Ph.D
a
Department of Ophthalmology, Inselspital, Bern University Hospital, and University of
Bern, Switzerland
Published online: 11 Aug 2015.

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To cite this article: S. Axmann MD, A. Ebneter MD, PhD & M. S. Zinkernagel MD, Ph.D (2015): Imaging of the Sclera in Patients
with Scleritis and Episcleritis using Anterior Segment Optical Coherence Tomography, Ocular Immunology and Inflammation

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 Ocular Immunology & Inflammation, Early Online, 1–6, 2015
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ISSN: 0927-3948 print / 1744-5078 online
DOI: 10.3109/09273948.2015.1025983

ORIGINAL ARTICLE

Imaging of the Sclera in Patients with Scleritis and

Episcleritis using Anterior Segment Optical
Coherence Tomography
S. Axmann, MD, A. Ebneter, MD, PhD, M. S. Zinkernagel, MD, Ph.D

Department of Ophthalmology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
Downloaded by [RMIT University] at 18:39 18 August 2015

ABSTRACT
Purpose: To evaluate the sclera and episclera in patients with scleritis and episcleritis using anterior segment
optical coherence tomography (AS-OCT).
Methods: Cross-sectional prospective case series of 11 consecutive patients with episcleral or scleral
inflammatory disease located anterior to the equator. The thickness of the ocular wall (sclera and the episclera)
was measured using AS-OCT and compared to the contralateral healthy eye.
Results: Eleven patients with a mean age of 49.5 years presented with symptomatic scleritis or episcleritis. The
mean thickness of the ocular wall in the affected eye was 982 ± 56 mm compared to 790 ± 23 mm (p50.05) in the
fellow eye. Enhanced-depth AS-OCT showed that the thickening occurred mainly in the episcleral layer in both
scleritis and episcleritis.
Conclusion: Enhanced-depth AS-OCT may be a useful tool for imaging scleritis or episcleritis and may serve to
monitor therapeutic success in these patients.
Keywords: Anterior segment OCT, episcleritis, scleritis

Scleritis is defined as inflammation of the sclera, and,
although it has characteristic clinical features, it is
sometimes confused with episcleritis, which is inflam-
mation confined to more superficial layers.
Differentiation of episcleritis and scleritis is impor-
tant, as management, prognosis, and complications
differ between these two diseases. Whereas episcler-
itis involves the superficial vessels and is not
associated with pain, scleritis is often painful and
may result in ocular complications, is more commonly
associated with systemic diseases and increased
mortality, and often requires systemic therapy.1,2
An understanding of the anatomy of the vascular
plexuses contained within the episclera and the sclera
is essential, especially to differentiate scleritis from
episcleritis; a superficial and a deep vascular layer can
be found within the episclera. The sclera itself is
avascular and has a low metabolic requirement
because of the slow turnover of collagen.3,4 While
the superficial episcleral vessels are mobile, the
deeper vessels are more attached to the sclera and
therefore immobile.
The use of phenylephrine eye drops can be helpful
in differentiating scleritis from severe episcleritis;
whereas the more superficial vessels constrict with
phenylephrine in episcleritis, the deeper vessels
affected in scleritis remain largely dilated.5,6
Anterior segment optical coherence tomography
(AS-OCT) is a relatively novel device developed to
provide multiple rapid, noncontact cross-sectional
images of the anterior segment.7 It has mainly been
used to evaluate corneal pathologies, but with the
introduction of the enhanced-depth imaging mode,
which allows the most tightly focused portion of the
illumination to be delivered to the deeper lying
tissue, the sclera can be imaged as well.7,8 With these

Received 29 November 2014; revised 15 February 2015; accepted 2 March 2015; published online 31 July 2015
Correspondence: Martin Zinkernagel, MD, PhD, Dept. of Ophthalmology, Inselspital, Bern University Hospital, Universität Bern, CH-3010
Bern, Switzerland. E-mail: martin.zinkernagel@insel.ch

1
 2 S. Axmann et al.
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FIGURE 1. Color photographs of eyes with episcleritis and scleritis. (A) Color images of a representative case with episcleritis in the
superior quadrant. (B) Color image of the same case with episcleritis after phenylephrine test. (C) Color images of a representative case
with scleritis in the superior quadrant. (B) Color image of the same case with scleritis after phenylephrine test.
technical advances, AS-OCT is now increasingly
being used beyond the cornea and the anterior
chamber angle to image structures such as the
sclera.9
The purpose of our study was to determine
whether it is feasible to obtain good-quality images
with AS-OCT in patients with episcleral or scleral
inflammation located anterior to the equator, and
whether this technique is able to identify changes
associated with inflammation.
MATERIALS AND METHODS
The study conformed to the provisions of the
Declaration of Helsinki and was approved by the
local ethics committee (KEK 178/12).
Between December 2013 and October 2014, 11
patients were prospectively enrolled for this study.
Patients presented themselves to the Department of
Ophthalmology at the Bern University Hospital.
General medical history and informed consent were
obtained from all patients. Visual acuity, slit-lamp
examination findings, the result of a 10% phenylephr-
ine test, and intraocular pressure from Goldman
tonometry were recorded. AS-OCT was conducted
and images were stored on the department server.
Patients were diagnosed with either scleritis or
episcleritis based upon symptoms (severity of pain),
slit-lamp appearance of the depth of the inflamma-
tion, the configuration of the vessels, and the outcome
of the phenylephrine test (Figure 1). None were taking
any anti-inflammatory or immunosuppressive drugs
at presentation.
Imaging and Image Analysis
For photographic documentation, the nasal and
temporal quadrants of each eye were photographed
using a slit-lamp mounted camera (Canon EOS 7D;
Canon, Wallisellen, Switzerland). OCT scans in the
nasal and temporal quadrants were acquired using a
spectral domain AS-OCT (Heidelberg Engineering,
Dossenheim, Germany). The sclera mode with EDI
was chosen with an OCT grid and the number of
B-Scans was 11 with a pattern size of 15  5
(8.3  2.8 mm) and the distance between B-Scans was
277 mm. The patients were asked to maintain either a
30 temporal or nasal gaze for imaging in order to
allow for perpendicular OCT imaging of the affected
sclera. Using the Heidelberg Eye Explorer software
(version 1.9.10.0; Heidelberg Engineering,
Dossenheim, Germany), the scleral thickness was
measured in the affected quadrant of the sclera and
compared to the contralateral unaffected quadrant of
the fellow eye. Because the sclera was difficult to
differentiate from the episcleral tissue due to con-
current inflammation, the thickness of the entire
ocular wall (sclera and episclera) was measured
(Figures 2 and 3). Three measurements were obtained
per raster scan and averaged.
To document the outcome of the phenylephrine
test, the color photographs were repeated 10 minutes
Ocular Immunology & Inflammation
 OCT Imaging of Scleritis and Episcleritis 3
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FIGURE 2. AS-OCT imaging of the sclera in the region of scleritis. (A) Representative color image. (B) Infrared image of the sclera. The
scan line (yellow) has been enhanced from the original for better visualization. (C) Enhanced depth spectral domain AS-OCT of the
scan in B. The white bar represents the measurement of the sclera in the area of scleritis. The white arrows highlight dilated vessels
within the deep vascular plexus (scale bar 200 mm) (n = 6).

FIGURE 3. AS-OCT imaging of the sclera in the region of episcleritis. (A) Representative color image. (B) Infrared image of the sclera.
The scan line (yellow) has been enhanced from the original for better visualization. (C) Enhanced depth spectral domain AS-OCT of
the scan in B. The white bar represents the measurement of the sclera in the area of episcleritis The white arrows highlight diffuse
swelling within the episcleral tissue (scale bar 200 mm) (n = 5).

! 2015 Taylor & Francis

 4 S. Axmann et al.
after application of 10% phenylephrine eye drops in
the affected eye.
Study data were collected and managed using
REDCap electronic data capture tools hosted at the
Department of Ophthalmology Inselspital, Bern
University Hospital, and University of Bern,
Switzerland. REDCap (Research Electronic Data
Capture) is a secure, web-based application designed
to support data capture for research studies.10
Statistics
Statistical data
analysis was performed using
GRAPHPAD PRISM version 6 for Windows (GraphPad
Software Inc., La Jolla, CA, USA). Paired and
unpaired two-tailed Student’s t test was used to
compare means, depending on the data, respectively.
P values 50.05 were considered statistically
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significant.
RESULTS
Eleven consecutive patients were included. The
female to male ratio was 7:4, and the mean age at
FIGURE 4. AS-OCT imaging of the sclera in the region of recurring scleritis over the course of a decade. (A) Time course with color
photographs of scleritis and corresponding year. (B1) AS-OCT image of the area shown in A in 2014, with (B2) corresponding en face
infrared image of the same patient highlighting the scan line (yellow), which has been enhanced from the original for better
visualization (scale bar 200 mm).
presentation was 49.5 years (min 19 y, max 77 y).
Based upon slit-lamp examination and phenylephrine
testing, 4 of the 11 patients were diagnosed with
nodular scleritis, 3 with diffuse scleritis, 2 with
nodular episcleritis, and 3 with diffuse episcleritis.
The affected quadrant was more frequently the
temporal (10 eyes) than the nasal one (single eye).
In the scleritis group, associations were found with
Hashimoto’s thyroiditis (1 patient) and varicella
zoster ophthalmicus (1 patient). In the episcleritis
group, associations were found with systemic lupus
erythematosus (1 patient). No other associations were
detected in the other patients.
The episcleral layers were thickened on OCT in
both scleritis and episcleritis. The deeper vascular
network showed a marked dilation of vessels extend-
ing (Figure 2) into the superficial layers of the sclera in
scleritis cases. In contrast, the vessels involved in
episcleritis were dilated more diffusely and more
superficially (Figure 3), and did not extend into the
sclera. One patient who had suffered recurring attacks
of scleritis over the 1-year period showed marked
thinning of the sclera (Figure 4). The mean thickness
of the sclera and episclera combined in episcleritis
was 952 ± 107 mm as compared to 764 ± 15mm in the
fellow eye (p = 0.158). Mean thickness in eyes with
Ocular Immunology & Inflammation

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FIGURE 5. Average thickness of ocular wall in the area of
episcleritis and scleritis compared to the collateral healthy eye
in the same scleral quadrant. (A) Representative OCT image of
the healthy contralateral eye and (B) OCT image of scleritis. The
red line represents the thickness of the ocular wall for better
visualization. Bar graph (bottom) of average thickness ± SEM of
ocular wall (sclera and episclera combined) for the study eye
(SE) and fellow eye (FE) (n = 11, *p50.05, ***p50.001).
scleritis was 1006 ± 58 mm as compared to 813 ± 39 mm
in the same quadrant of the fellow eye (p50.05).
When combining both groups, mean thickness in the
affected eye was 982 ± 56 mm as compared to
790 ± 23 mm in the fellow eye (p50.05) (Figure 5).
DISCUSSION
Using spectral domain AS-OCT, we not only demon-
strate that the episclera and sclera can be imaged in
great detail, but also that the changes observed on
OCT correlate well with the clinical diagnosis based
on patients’ symptoms, slit-lamp appearance, and
phenylephrine testing. Eyes with scleritis, but not
episcleritis, had statistically thicker eye wall com-
pared to the uninvolved fellow eye. Because of the
concomitant inflammation in eyes with scleritis or
episcleritis, we measured the entire eye wall (sclera
and episclera combined), as this provided more
consistent results. The AS-OCT finding that in
! 2015 Taylor & Francis
OCT Imaging of Scleritis and Episcleritis 5
episcleritis only the superficial layers are involved,
whereas in scleritis deeper layers show evidence of
dilated vessels in the deeper vascular network, are in
keeping with previous reports.3,5
Fifteen years ago, Heiligenhaus et al. evaluated
ultrasound biomicroscopy (UBM) as a tool for detect-
ing and following up scleritis and episcleritis.2 They
showed that UBM was helpful in rapidly differentiat-
ing scleritis from severe episcleritis, detecting the
diverse scleritis types, disclosing disease progression,
and judging treatment efficacy.2 However, since then,
AS-OCT has become much more widely available
than UBM. Like UBM, AS-OCT allows for a rapid
in vivo evaluation of scleritis and episcleritis.
Moreover, AS-OCT is a noncontact examination
technique, adding much to patients’ comfort.
A limitation of our study is the small number of
patients. This is mainly due to the low prevalence of
scleritis and episcleritis, which is estimated to be
approximately 6 cases per 100,000 people.11
Furthermore, we were not able to include patients
with necrotizing scleritis during the recruitment
period; however, using AS-OCT, we were able to
show that recurrent scleritis is associated with marked
thinning of the sclera. In addition, we did not evaluate
AS-OCT as a tool for assessing disease progression or
remission. However, even with the relatively small
sample size, scleral thickening seen in AS-OCT was
highly consistent, and although the increase in scleral
thickness in the episcleritis group did not reach
statistical significance, well-defined changes were
seen on the AS- OCT images. Considering ever
higher resolution and the ability to image increasingly
dense tissues such as the sclera with OCT, it may
become possible to differentiate various types of
scleral inflammation on anatomical findings alone.
In conclusion, the findings of this study indicate
that AS-OCT is a useful, rapid, and noninvasive tool
for analyzing the depth of anterior segment inflam-
mation, and may be helpful to quantify the extent of
scleral involvement. Furthermore, our results show
that AS-OCT may be used to monitor therapeutic
effects in scleral and episcleral inflammatory disease.
Larger studies are needed in order to assess AS-OCT
as a tool to efficiently differentiate scleritis anterior to
the equator from severe episcleritis.
DECLARATION OF INTEREST
The authors report no conflict of interest. The authors
alone are responsible for the content and writing of
the paper.
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