Scleritis: Scleral Inflammation
Definition
Scleritis refers to the inflammation of the sclera, which is the dense connective tissue forming the structural support of the eye. The condition can affect vision and is often associated with systemic autoimmune diseases.
Types of Scleritis
1. Anterior Scleritis:
- Diffuse Anterior Scleritis: Widespread inflammation with a better prognosis.
- Nodular Anterior Scleritis: Localized inflammation forming nodules.
- Necrotizing Anterior Scleritis: Severe, painful, and potentially sight-threatening.
2. Posterior Scleritis: Affects the back portion of the sclera and may mimic orbital or retinal conditions, making diagnosis challenging.
Causes
- Autoimmune Diseases: Rheumatoid arthritis, systemic lupus erythematosus (SLE), granulomatosis with polyangiitis, relapsing polychondritis.
- Infectious Causes: Bacterial (e.g., tuberculosis, syphilis), viral (e.g., herpes simplex, herpes zoster), fungal (e.g., aspergillosis).
- Trauma: Physical or chemical injuries.
- Idiopathic: No identifiable cause in some cases.
Signs and Symptoms
- Severe, deep eye pain that may radiate to the jaw or temple.
- Redness of the eye, particularly a violaceous hue.
- Swelling of the sclera.
- Sensitivity to light (photophobia).
- Blurred vision or loss of vision.
- Tearing or watery eyes.
- Presence of nodules or necrotic areas in severe cases.
Diagnosis
- Clinical Examination: Detailed slit-lamp examination to identify inflammation.
- Patient History: Evaluation for systemic autoimmune or infectious diseases.
Investigations
- Blood Tests: Rheumatoid factor (RF), antinuclear antibody (ANA), antineutrophil cytoplasmic antibodies (ANCAs), ESR, and CRP.
- Imaging: B-scan ultrasonography, CT, or MRI for orbital involvement.
- Microbiological Tests: Cultures for suspected infections.
Treatment
Medical Management
- Non-Infectious Scleritis:
- NSAIDs: Indomethacin (25-50 mg three times daily).
- Corticosteroids: Prednisone (1 mg/kg/day).
- Immunosuppressive Agents: Methotrexate, azathioprine, or mycophenolate mofetil; biologics like infliximab for refractory cases.
- Infectious Scleritis:
- Antibiotics: Ciprofloxacin, ceftriaxone.
- Antiviral: Acyclovir for herpes-related infections.
- Antifungal: Voriconazole or amphotericin B.
Medications to Avoid
Avoid corticosteroids in active infections as they can worsen the condition.
Role of Vitamins
- Vitamin A: Maintains corneal health and tear production.
- Vitamin D: Reduces inflammation and modulates immune responses.
- Vitamin C: Promotes collagen synthesis and scleral repair.
- Vitamin E: Acts as an antioxidant, protecting eye tissues from damage.
Episcleritis vs Scleritis
| Feature | Episcleritis | Scleritis |
|---|---|---|
| Definition | Inflammation of the episclera, the thin layer between the conjunctiva and sclera. | Inflammation of the sclera, the white outer coat of the eye. |
| Severity | Usually mild and self-limiting. | Severe, potentially vision-threatening. |
| Pain | Mild or no pain. | Moderate to severe, deep eye pain, often radiating to the head or face. |
| Appearance | Redness localized in a wedge shape, often bright red. | Diffuse or localized redness, often a darker, bluish-red hue. |
| Associated Conditions | Rarely associated with systemic diseases. | Often associated with systemic autoimmune diseases like rheumatoid arthritis or vasculitis. |
| Response to Treatment | Responds well to topical or no treatment. | Requires systemic treatment, such as oral steroids or immunosuppressants. |
| Recurrence | Recurrence is uncommon. | Recurrence is common, especially if associated with systemic conditions. |
Lifestyle Effects and Management
- Lifestyle Impacts: Reduced ability to perform daily tasks, psychological effects like stress and anxiety.
- Lifestyle Adjustments: Use sunglasses, avoid contact lenses, follow a healthy diet rich in antioxidants.
Complications
- Corneal thinning and perforation.
- Glaucoma due to elevated intraocular pressure.
- Retinal detachment in posterior scleritis.
- Permanent vision loss in severe or untreated cases.
Management Strategies
- Regular Monitoring: Frequent evaluations to monitor progression and response.
- Systemic Disease Management: Collaboration with specialists.
- Supportive Care: Pain management and emotional support.
Conclusion
Scleritis is a serious ocular condition that requires early diagnosis and appropriate treatment to prevent complications. Multidisciplinary care involving ophthalmologists, rheumatologists, and infectious disease specialists is often essential for optimal outcomes.