Scleritis is a serious eye condition characterized by inflammation of the Sclera, the white part of the eye. 

This inflammation causes the Sclera to turn red, leading to discomfort and potential vision loss.

According to a 2022 article, Scleritis affects middle-aged people between 47-60 years, and women are more susceptible to contracting the disease, with about 60% to 74% of cases occurring in females.

Recognizing the signs and seeking prompt medical attention for appropriate treatment is essential. 

This article will delve into this condition and learn more about its types, symptoms, causes, diagnosis, and management.

Symptoms

The common symptoms of Scleritis include:

Types of Scleritis

Anterior scleritis
Anterior scleritis

There are different types having distinct features:

Anterior Scleritis (front of the Sclera)

This is the most common type, affecting the front part of the eye.

There is mild to moderate pain, which worsens at night and with eye movement. 

The blood vessels may appear blue-violet. People experience light sensitivity, tearing, and possibly reduced vision.

Diffuse Scleritis

This type is the most frequent, and the inflammation spreads across the Sclera with congestion of blood vessels. 

It can affect a large or small area of the front part of the eye.

Nodular Scleritis

This type has multiple, well-defined, and non-moveable nodules on the Sclera. 

It is concentrated in one area, causing a nodule, swelling, and redness.

Necrotizing Scleritis

This is the most severe form, and it is associated with intense vessel congestion and severe pain. 

It can lead to thinning of the Sclera, exposing the underlying layer, the Choroid, which can cause the loss of the entire eye.

There is a specific subtype of Necrotizing Scleritis called “Scleromalacia Perforans,” which can result in holes in the eye.

Posterior Scleritis (back of the Sclera)

It is a rare form that affects the back part of the eye, behind the rectus muscle.

People may experience decreased vision characterized by retinal detachments, optic nerve swelling, and cotton wool spots. 

Causes

The exact cause of Scleritis is sometimes unknown and may develop suddenly without any identifiable sign.

However, the Sclera’s structural composition and limited blood supply make it vulnerable to inflammation.

In some cases, it can be contracted because of other diseases and factors like:

Infections

Infections, including viral, bacterial, fungal, and parasitic, can be the cause. 

However, it is relatively uncommon, accounting for approximately 4% to 10% of all cases.

Autoimmune illness

Scleritis can be associated with various autoimmune diseases. Here are some of them with their impact on the body,

  • Rheumatoid arthritis affects joints on both sides of the body
  • Systemic Lupus Erythematosus causes chronic inflammation and affects multiple organs, joints, and skin
  • Inflammatory bowel disease (IBD) is a disorder leading to chronic inflammation in the intestines
  • Sjogren’s syndrome is an autoimmune disorder that reduces moisture production in the eyes and mouth
  • Scleroderma, where dense, thick fibrous tissue replaces normal tissue
Warning:
In the autoimmune condition, the immune system mistakenly attacks healthy cells, tissues, and organs. These attacks can weaken bodily function and even become life-threatening.
So, early diagnosis and treatment are crucial in managing the potential complications of an autoimmune condition.

Malignancy

Ocular inflammation caused by Choroidal Melanomas and Conjunctival tumors can imitate the signs and symptoms.

Surgically induced

Some cases have been associated with specific surgical procedures, such as Pterygium removal and Scleral buckle procedures.

Additionally, Surgically Induced Necrotizing Scleritis (SINS) is an example of infectious Scleritis that can arise due to eye surgery.

Medication side effects

Certain medications, such as Bisphosphonates used to treat Osteoporosis, be the cause, although such side effects are rare. 

Complications in Scleritis

It can lead to various complications depending on the severity of related autoimmune conditions. 

Some possible complications include:

  • Decreased vision: It can affect the clarity of vision, making it difficult to see clearly
  • Cataracts: The risk of cataracts may be increased, clouding the eye’s natural lens
  • Increased intraocular pressure: It can cause the pressure inside the eye to rise
  • Scleral thinning or melting: In severe cases, the Sclera can become thin or even start to dissolve
  • Corneal thinning: The cornea, the transparent front part of the eye, can also become thinner
Did you know?
Cataract is a common eye condition that clouds the eye’s natural lens. This clouding causes blurred vision and can lead to significant vision loss if left untreated. Cataract typically develops over time and is most commonly associated with aging.

Who does it affect?

Scleritis mainly affects individuals in their middle age, usually between the ages of 47 and 60.

Women are more commonly affected than men, accounting for more than half of cases. Though, the reason why women are more at risk is not entirely clear.

While it can occur in children, the chances of that happening are relatively low, making it a rare condition in kids.

Diagnosis and tests

Doctors rely on clinical assessment, eye examination, and various tests to diagnose Scleritis. 

Here are the common diagnostic methods used:

Clinical assessment and eye exam

Slit Lamp Exam
Slit lamp exam

Doctors carefully examine the eye, review medical history, and check for symptoms like redness, pain, and sensitivity to light. 

A doctor can also perform a slit lamp exam for an eye examination.

In this, a special microscope with a bright light is used to examine the eye structures, including the Sclera.

Laboratory tests

Various blood tests are conducted to detect inflammation and autoimmune conditions.

Common lab tests include:

  • ANCAs are used specifically for Granulomatosis with Polyangiitis
  • ANA is used in Systemic Lupus Erythematosus and other autoimmune conditions
  • CBC with differential helps identify any infections or inflammatory processes
  • Erythrocyte Sedimentation Rate (ESR) test Indicates giant cell arteritis and inflammatory conditions
  • Lyme serology is used to test for Lyme Disease, which can cause anterior Scleritis, frequently
  • Rheumatoid factor helps in diagnosing Rheumatoid Arthritis
  • ACE and Serum lysozyme is conducted to diagnose Sarcoidosis
  • RPR and FTA-ABS help in testing for Syphilis

Imaging studies

Various imaging techniques are used to assess the eyes and surrounding body parts. These include:

  • Chest X-Ray is done to rule out Sarcoidosis
  • B-scan helps in detecting Posterior Scleritis
  • MRI and CT are conducted  if B-scan results are inconclusive
  • Ultrasound Biomicroscopy (UBM) is conducted to differentiate between Scleritis and Episcleritis
  • Optical Coherence Tomography (OCT) shows that the Sclera is thicker than normal in the front of the eye. It also reveals the thickening of the Choroidal tissue
  • Anterior Segment Fluorescein and Indocyanine Green Angiography (ICGA) is useful in assessing Necrosis

Treatment and management

The treatment and management aim to address the underlying cause and reduce eye inflammation and pain. 

Here is an overview of the treatment options for scleritis based on its different types and severity:

Anterior Infectious Scleritis

The treatment for infectious Scleritis is tailored to the specific infectious cause and typically involves topical and systemic antibiotics or antiviral medications. 

Proper identification of the causes is crucial in guiding the choice of antibiotics or antiviral drugs.

Anterior Non-infectious Scleritis

For non-infectious Scleritis the following line of treatment is followed:

  • Topical Corticosteroid eyedrops: In mild cases, topical corticosteroids may be used, but their success is limited
  • Oral NSAIDs (Nonsteroidal Anti-Inflammatory Drugs): These can be used as initial therapy. Options include Indomethacin, Ibuprofen, and Naproxen 
  • Oral Corticosteroids: Oral Corticosteroids like Prednisone are prescribed if oral NSAID treatment fails to control the inflammation adequately
  • Immunosuppressive agents (steroid-sparing): Reserved for more severe cases of Scleritis where oral steroid treatment has failed. Methotrexate, Azathioprine, Mycophenolate, and Cyclophosphamide are prescribed
  • Biologics: Biologics like Infliximab and Rituximab for their positive treatment response. These agents may be considered in refractory cases of Scleritis

Posterior Scleritis:

This requires intense and immediate treatment.

  • Oral NSAIDs: Similar to anterior noninfectious Scleritis, oral NSAIDs like Indomethacin, Naproxen, and Ibuprofen can be used initially
  • Oral corticosteroids: If NSAID treatment fails to control the inflammation effectively, oral Corticosteroids are prescribed at a higher dose
  • Immunosuppressive agents: Reserved for severe cases of Posterior Scleritis. Commonly prescribed agents include Methotrexate, Azathioprine, and Mycophenolate
  • Biologics: In some cases of refractory Posterior Scleritis, biologics like Infliximab and Rituximab may be considered for their potential benefits.
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Prevention

Prevention of Scleritis can be challenging since it is often associated with underlying autoimmune disorders or can occur as a complication following certain ocular surgeries. 

However, there are some measures that can be taken to reduce the risk of developing Scleritis: 

  • Prompt diagnosis and treatment: You should seek immediate medical attention for eye pain, redness, or vision changes
  • Manage underlying autoimmune disorders: If you have any autoimmune diseases, then work closely with physicians to control underlying conditions
  • Regular ophthalmologist visits: Visit your eye doctor regularly, particularly important for those with autoimmune disorders or prior Scleritis
  • Informed consent and awareness: Patients undergoing surgeries with potential Scleritis risk should be fully informed about complications and outcomes, enabling them to make informed decisions and recognize warning signs promptl
  • Adopt a healthy lifestyle: While there is no specific lifestyle change to prevent Scleritis, maintaining a balanced diet, exercising, managing stress, and avoiding smoking/alcohol can contribute to overall well-being

Conclusion

Scleritis is a serious inflammatory eye condition that can lead to discomfort, vision loss, and even potential eye damage if left untreated. 

Causes cannot be determined easily and are associated with other medical conditions, like autoimmune diseases. 

Diagnosing involves a thorough clinical assessment, eye examination, and specific laboratory tests and imaging studies to determine the underlying cause and severity. 

Treatment options aim to reduce inflammation and pain.

It involves using Corticosteroid eye drops, oral NSAIDs, or immunosuppressive agents, depending on the severity of the condition.

While prevention may not always be possible, maintaining good eye hygiene and using protective eyewear can reduce the risk of infections and eye injuries.

Early detection, timely medical intervention, and proper management are essential in effectively addressing the condition and preserving eye health.

Frequently Asked Questions

How do you stop Scleritis?

To stop and manage it effectively, seeking medical attention from an eye specialist is crucial. Treatment options may include topical Corticosteroids (eye drops or ointments) for mild cases, oral NSAIDs (Indomethacin, Naproxen, Ibuprofen) to manage pain and inflammation, and oral Corticosteroids for severe cases.

Can vitamin D deficiency cause Scleritis?

There is limited evidence linking vitamin D deficiency directly to the condition. It is primarily associated with autoimmune diseases, infections, and other underlying medical issues. However, maintaining adequate vitamin D levels is essential for overall health and may help support the immune system. 

What are the risk factors?

It has several common risk factors. It is often associated with autoimmune conditions like Rheumatoid Arthritis, Lupus, and Inflammatory Bowel Disease. Eye trauma or surgery and certain medications can trigger the condition.

What is the leading cause of Scleritis?

The exact cause of Scleritis is often unknown and can develop without an identifiable trigger. However, it is strongly associated with autoimmune diseases. The immune system mistakenly attacks its tissues, leading to inflammation. Infections, eye trauma, and certain medications may also play a role. 

Citations:
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