SCLERITIS, ATLAS OF SCLERITIS, The Atlas of Emergency Medicine, Fourth Edition, OPHTHALMIC CONDITIONS
Clinical Summary
Scleritis is painful, destructive, and potentially blinding. The pain is constant and boring and may radiate to the face and periorbital region. Associated features include tearing, photophobia, globe tenderness to palpation, and painful ocular movement.
The conjunctival vessels are injected. The eye itself may be intensely red with a violaceous or purple hue secondary to engorgement of the deep vessels of the episclera and scleral thinning. These deep vessels do not move when the overlying conjunctiva is moved with a cotton-tipped applicator, nor do
they blanch with topical phenylephrine. On slit-lamp microscopy, the episcleral vessels are displaced outward by scleral edema. Corneal involvement, iritis (with cells and flare in the anterior chamber), and decreased visual acuity may accompany scleritis. An associated scleritis may occur with severe
infectious keratitis. Primary infectious scleritis is rare. In either instance, topical and systemic antibiotics are indicated after appropriate cultures are obtained.
In up to 50% of cases, scleritis is associated with underlying autoimmune or infectious systemic disease, rheumatoid arthritis the most common. It occurs more frequently in women and in the fourth to sixth decades of life.
FIGURE 2.25 ■ Scleritis. A prominent generalized vascular injection is present.
A bluish hue is also seen superiorly due to scleral
thinning. These vessels do not move when the overlying conjunctiva
is moved with a cotton-tipped applicator.
FIGURE 2.26 ■ Scleritis. A 55-year-old female with scleritis of
the left eye associated with rheumatoid arthritis. Note dilation of
the deep conjunctival and episcleral vessels and blue hue suggesting
thinning of the sclera temporally.
FIGURE 2.27 ■ Sectorial Scleritis. Deep-boring pain experienced
by this patient distinguishes this segmental area of erythema from
episcleritis.
Management and Disposition
Ophthalmology consultation is required. Treatment varies according to underlying disease (if present), and can involve NSAID therapy, glucocorticoids, and immunosuppressive medications. Rheumatology consultation by the ophthalmologist is often required for optimal management in patients with underlying autoimmune disorders.
Pearls
1. Scleritis is associated with a systemic disease in approximately 50% of cases, most commonly rheumatoid arthritis.
2. Most cases of scleritis involve the anterior portion (anterior to the insertion of the medial and lateral rectus muscles).
3. Pain is exacerbated with ocular movements because the extraocular muscles insert into the sclera itself.
4. Anterior uveitis can occur in up to 40% of patients because the uvea is immediately adjacent to the sclera.
5. Check intraocular pressure (IOP) to rule out acute ACG as another cause of painful red eye.
The Atlas of Emergency Medicine, Fourth Edition, 2016.
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