SCLERITIS AND

EPISCLERITIS

SCLERITIS
A PRIMARY INFLAMATION OF THE
SCLERA severe eye pain
98% ANTERIOR
DIFFUSE ANTERIOR
NODULAR
NECROTIZING
SCLEROMALACIA PERFORANS

SCLERITIS

4 Types of anterior scleritis

1.
2.
3.
4.

Diffuse anterior scleritis

Nodular anterior scleritis Erythematous
Necrotizing anterior scleritis
Scleromalacia perforans

EPISCLERITIS
CHARACTERISED BY :
INFLAMATION OF THE EPISCLERA
YOUNGER PATIENTS
WOMEN
7 10 DAYS SPONTANNEOUSLY RESOLV
ASSOCIATED SYSTEMIC DISEASE

NODULER EPISCLERITIS

PRESENTATION
EPISCLERITIS

SCLERITIS

PRESENTATION

Acute onset
Mild pain/discomfort
Localised or diffuse red eye
Uni or bilateral
No associated ocular symptoms
other than watering, vision
normal.

Usually gradual onset

Severe boring eye pain often
radiating to forehead, brow and
jaw
Localised or diffuse red eye
Uni/ bilateral
Associated watering,
photophobia and gradual
decrease in vision
Scleromalacia perforans may
present with minimal/ no
symptoms

PAST HISTORY

Recurrent episodes common

May be associated with
systemic disease

Recurrent episodes common

Commonly associated with
systemic disease which may be
severe

2. PATHOPHYSIOLOGY
Maite Sainz de la Maza An autoimmune dysregulation in a
genetically predisposed host Scleritis
Inciting factors may include infectious organisms, endogenous
substances, or trauma.
The inflammatory process my be caused by immune complex
related vascular damage ( type III ) and chronic granulomatous
response ( type IV).

50 % ASSOCIATED WITH SYSTEMIC DISEASE:

Rheumatoid arthritis
Ankylosing spondylitis
SLE
Polyarteritis nodosa
Wageners granulomatosis
Herpes zoster virus
Gout and syphilis

3. CLINICAL FEATURES

Redness Sclera and Conjunctiva purple hue

Severe ocular pain
Increased light sensitivity and tearing
Loss of vision

Simptoms:

Pain
Tearing or Photophobia
Tenderness
Decreased visual acuity

Primary Sign: Redness

Descriptions of Pain:
- Severe, penetrating pain; forehead,
brow, jaw or sinuses
- Awakens the patient during the night
- Exacerbated by touch; extremely tender
- Only temporily relieved by analgesics

Applied anatomy of vascular coats

Normal

Episcleritis

Radial superficial episcleral

Maximal congestion
vessels
of episcleral vessels
Deep vascular plexus
adjacent to sclera

Scleritis

Maximal congestion of
deep vascular plexus
Slight congestion of
episcleral vessels

Simple episcleritis
Common, benign, self-limiting but frequently recurrent
Typically affects young adults
Seldom associated with a systemic disorder

Simple sectorial episcleritis

Simple diffuse episcleritis

Nodular episcleritis
Less common than simple episcleritis
May take longer to resolve
Treatment - similar to simple episcleritis

Deep scleral part of slit-beam

Localized nodule which can be moved over sclera
not displaced

Diffuse anterior non-necrotizing scleritis

Relatively benign - does not progress to necrosis
Widespread scleral and episcleral injection

Nodular anterior non-necrotizing scleritis

More serious than diffuse scleritis

On cursory examination resembles

nodular episcleritis

Scleral nodule cannot be moved over

underlying tissue

Anterior necrotizing scleritis with inflammation

(scleromalacia perforans)
Associated with rheumatoid arthritis
Asymptomatic and untreatable

Progressive scleral thinning with exposure of underlying uvea

Anterior necrotizing scleritis with inflammat

Painful and most severe type

Complications - uveitis, keratitis, cataract and glaucoma
Progression

Avascular patches

Scleral necrosis and

visibility of uvea

Spread and coalescence

of necrosis

Posterior scleritis
1. External findings ~ restriction of eye movements
sensitivity to palpation
proptosis.
2. Fundus to identify ~ amelanotic choroidal
choroidal folds
papilledema
retinal hemorrhage
detachment

Posterior scleritis

About 20% of all cases of scleritis

About 30% of patients have systemic disease
Treatment similar to necrotizing scleritis with inflammation

Signs

Proptosis and
ophthalmoplegia

Ring choroidal
detachment

Disc swelling

Choroidal folds

Exudative retinal
detachment

Subretinal exudation

Imaging in posterior scleritis

Ultrasound

Axial CT
a

a - Thickening of posterior sclera

b -Fluid in Tenon space (T
sign)

Posterior scleral thickening

4. OCULAR COMPLICATIONS

Vision loss
Eye destruction
Peripheral ulcerative keratitis ( 13 14% )
Uveitis ( 42% )
Glaucoma ( 12 - 13% )
Cataract ( 6 17% )
Fundus abnormalities ( 6,4% )

Necrotizing scleritis

5.TREATMENT

1. Oral NSAID
2. Oral prednisolone
3. Combined therapy
4. Subconjunctival steroid injection

TREATMENT

Severe cases of Necrotizing scleritis repair

Less severe cases NSAID, such as Ibuprofen 100
mg
In some cases Corticosteroids, Antibiotics and an
eye solution