Scleritis

What's going on?

The sclera is firmly packed collagen. It is thus susceptible to involvement with system collagen vascular disorders. Scleritis is inflammation of the sclera and has significant associated ocular morbidity. An associated systemic disease is identified in 50% of patients with scleritis.

Pain is an important feature in differentiating scleritis from episcleritis. In episcleritis there is some discomfort but not the boring, aching pain and tenderness associated with scleritis.

If I examine the patient, what will I find?

This condition may be necrotising or non-necrotising.

In the necrotising variety, there is scleral inflammation with 'beefy'-red dilated scleral blood vessels surrounding a white avascular area of sclera. Necrotising scleritis is the more severe type and is associated indirectly with significant subsequent mortality from on-going systemic vasculitis.

In the non-necrotising type, there will be marked localised 'beefy' dilated vasculature.

What if I've diagnosed it?

Patients should be referred soon/urgently.

What will the hospital do?

We will assess the patient's systemic inflammatory status. If there is no underlying diagnosis, bloods will be taken for an autoimmune screen and a chest X-ray will be carried out.

Some patients respond to systemic NSAIDs, while others require systemic immunosuppression.

What do I need to do?

The presence of scleritis can be a reflection of active systemic disease. If the patient is already known to have a collagen vascular disorder such as rheumatoid arthritis, their disease activity should be reassessed and re-referral to a rheumatologist considered. The patient may require systemic immunosupression.

What to tell the patient

They have severe inflammation of the wall of the eye (sclera) that needs to be calmed with tablets (sometimes strong immunosuppression drugs). The condition of the eye indicates that their systemic disease (if they have one) is active, so that also needs attention.

Problems that may arise, and how to deal with them

Severe active scleritis is correlated with increased mortality in the subsequent years from systemic disease activity. The patient's systemic disease control should be carefully monitored and optimised.