Scleritis

Definition

Scleritis is the inflammation of the outer white wall of the eye called sclera. It is a chronic condition that can potentially blind the person. Scleritis is characterized by edema and cellular infiltration of the scleral as well as episcleral tissues

Classifications of scleritis

Scleritis is classified based on the section of the sclera that is inflamed. It can be anterior or posterior.

Anterior scleritis is when sclera at the front of the eyeball inflamed. It is of following 4 types:

• Diffuse anterior scleritis
  • Common type of scleritis
  • Extensive inflammation of the anterior sclera
  • Treatable
  • No threat to vision
• Nodular anterior scleritis
  • Small red, tender nodules (or swellings) form on the sclera
  • Recurring condition
  • Progresses to necrotising scleritis
• Necrotising anterior scleritis
  • Less common type
  • Characterized by extreme pain and damage to the sclera
  • Have an associated systemic disease
• Necrotising anterior scleritis without inflammation (Scleromalacia perorans)
  • Bilateral form (affects both eyes)
  • No symptoms
  • Associated with systemic autoimmune disorders like advanced rheumatoid arthritis, mostly in women

Posterior scleritis is when sclera at the back of the eyeball is inflamed. It causes flattening and thickening of the posterior part of the eye along with retro bulbar edema

Affected population

• People between the ages of 30 and 60
• Women are affected more often than men

• People with underlying systematic auto-immune inflammatory disorder like:
  • Rheumatoid arthritis
  • Wegener’s granulomatosis
  • Relapsing polychondritis
  • Polyarteritis nodosa
  • Systemic lupus erythematosus
  • Giant cell arteritis
  • Inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis
• People who had undergone ocular or eye surgery

Causes of Scleritis

Most of the cases of scleritis have an underlying systematic auto-immune inflammatory disorder but in some cases, it remains idiopathic.

• Systematic auto-immune inflammatory disorder like:
  • Rheumatoid arthritis
  • Wegener’s granulomatosis
  • Relapsing polychondritis
  • Polyarteritis nodosa
  • Systemic lupus erythematosus
  • Giant cell arteritis
  • Inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis
• Viral or bacterial infections like:
  • Lyme disease
  • Shingles
  • Tuberculosis
  • Syphilis

• Miscellaneous reasons:

• Gout
• High blood pressure

Inciting factors of Scleritis:

• Infectious organisms
• Endogenous substances
• Blunt or penetrating ocular trauma
• Drugs, such as pamidronate, alendronate etc.

Symptoms of scleritis

• Redness on the normally white part of the eye, either small or covering the entire front part of the eye
• A severe, persistent, deep boring or pulsating pain in the eye
• Pain worsening on eye movement
• Intense pain that can make patient wake up at night
• Extremely tender eye
• Watering or tearing from the eyes
• Blurred vision
• Loss of vision
• Pain causing sensitivity to light
• Pain in eyebrow, temple or jaw
• Very rarely it may cause no eye pain or redness

Exams and Tests for Diagnosis of Scleritis

Correct and prompt diagnosis of scleritis is very important to start appropriate treatment to stop the progression of both ocular and systemic disease. A thorough history and systemic review of the patient plays major role while diagnosing scleritis as most of the patients with scleritis has some associated systemic disorder. Finally, an eye examination and blood tests helps to confirm the scleritis and systemic disorder.

Treatment of scleritis

Although scleritis is not an emergency condition but it can cause thinning of sclera leading to its tear or hole formation. It can also damage cornea or lead to vision loss. So, immediate attention and treatment of scleritis is required.

Medical Care:

Systemic therapy to treat associated disease, such as rosacea, gout, atopy, or infection, is the first step while treating scleritis.

Other than this, treatment depends upon the type of scleritis:

Treatment for non-infectious scleritis:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Corticosteroids
• Immunomodulatory drugs

Treatment for diffuse scleritis or nodular scleritis

• NSAID
• Oral corticosteroids
• Immunosuppressive drugs
• Biologic response modifiers
• Periorbital and subconjunctival steroid injections

Treatment for necrotizing scleritis

• Immunosuppressive drugs with corticosteroids
• Biologic response modifiers
• Periocular steroid injections

Treatment for infectious scleritis

• Systemic treatment with or without topical antimicrobial therapy

Surgical Care

In some cases, tectonic surgical procedure or scleral graft surgery is required to preserve the integrity of the eye.