Scleritis

Full thickness inflammation of the sclera; more serious than episcleritis

Aetiology

Scleritis is commonly associated with systemic disease, although idiopathic cases also occur.

Autoimmune and Systemic Associations

  • Rheumatoid arthritis (most common)
  • Granulomatosis with polyangiitis
  • Systemic lupus erythematosus
  • Relapsing polychondritis
  • Polyarteritis nodosa
  • Inflammatory bowel disease

Infectious Causes (Less Common)

  • Herpes simplex virus
  • Herpes zoster virus
  • Mycobacterium tuberculosis
  • Treponema pallidum
  • Fungal infections (post-surgical or traumatic)

Idiopathic

  • No identifiable cause in up to one-third of cases

Clinical presentation

Symptoms

  • Severe, deep, boring ocular pain radiating to the temple, jaw, or brow
  • Pain exacerbated by eye movement or at night
  • Photophobia
  • Tearing
  • Decreased visual acuity

Signs

  • Diffuse or sectoral violaceous scleral injection
  • Deep episcleral vessels that are immobile
  • Localized scleral tenderness
  • Scleral thinning or bluish discoloration (in advanced disease)
  • Possible associated keratitis, uveitis, or glaucoma
notion image

Management

Management requires a stepwise and often systemic approach.

Medical Therapy

  1. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
      • First-line for mild, non-necrotizing anterior scleritis
  1. Systemic Corticosteroids
      • Indicated in moderate to severe disease or NSAID-refractory cases
  1. Immunosuppressive Agents
      • Methotrexate, azathioprine, cyclophosphamide
      • Biologic agents (e.g., rituximab, TNF-α inhibitors) for refractory disease
  1. Antimicrobial Therapy
      • Required in infectious scleritis (steroids contraindicated until infection controlled)

Surgical Management

  • Reserved for complications such as scleral thinning or perforation
  • Requires careful control of inflammation prior to intervention