Individuals with scleritis usually present with tenderness and dull pain in the affected eye and periocular area. The pain may worsen with eye movements and radiate to the face, cheek, and jaw. When cornea or posterior sclera is involved, vision may be affected.
The eye with scleritis typically shows scleral edema and intense hyperemia (Fig 7-1), leading to a characteristic violaceous hue on external examination. Slit-lamp examination characteristically discloses marked dilation of deep episcleral plexus, which is displaced outward by scleral edema/inflammatory infiltration. This is important in the distinction from episcleritis, in which no scleral edema is found and only superficial episcleral plexus is affected. Careful utilization of a topical vasoconstrictor (eg, phenylephrine drops) to bleach superficial blood vessels may facilitate this assessment and help distinguish episcleritis, in which the redness would blanch with phenylephrine, from scleritis. Close biomicroscopic inspection is also very important to assess the presence of signs of necrotizing disease (Fig 7-2).
Figure 7-1 Diffuse anterior scleritis, with dilation of deep episcleral vessels before (A) and after (B) instillation of phenylephrine.
(Courtesy of H. Nida Sen, MD/National Eye Institute.)
Figure 7-2 Anterior necrotizing scleritis, showing active scleral inflammation associated with an avascular area close to the limbus, adjacent to an area of scleral thinning.
(Courtesy of Daniel V. Vasconcelos-Santos, MD, PhD.)
Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA, Doctor PP, Tauber J, Foster CS. Clinical characteristics of a large cohort of patients with scleritis and episcleritis. Ophthalmology. 2012;119(1):43–50.
Sainz de la Maza M, Vitale AT. Scleritis and episcleritis. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 2009, module 4.
Diffuse Anterior Scleritis
Anterior scleritis is defined as scleral inflammation anterior to the recti muscles. This is the most common and least severe type of scleritis, with a less than 10% risk of complications in most individuals. Onset is frequently insidious, with severe pain and diffuse or sectoral deep episcleral vascular congestion. Scleral swelling/infiltration is more diffuse (see Fig 7-1), so that no nodule is formed. Recurrences are very common. The main systemic associations include rheumatoid arthritis, systemic lupus erythematosus, and relapsing polychondritis. Inflammatory bowel disease, reactive arthritis, and, less frequently, ankylosing spondylitis can also be implicated.
Excerpted from BCSC 2020-2021 series: Section 9 - Uveitis and Ocular Inflammation. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.