Scleritis is a painful inflammation of the sclera, the tough white wall of the eye. About half of cases are linked to an autoimmune disease such as rheumatoid arthritis or granulomatosis with polyangiitis, and severe forms can damage vision.
Key symptoms
- Severe, deep, boring eye pain that can wake the patient at night
- Pain spreading to the brow, temple or jaw
- Red eye, sometimes with a violet tint
- Tearing and light sensitivity
- Blurred vision in severe cases
What you find on exam
- Deep red or bluish color of the sclera
- Eyeball tender to touch
- Redness does not fade with phenylephrine drops, unlike episcleritis
- Slit lamp: scleral swelling, thinning or nodules
- Joint, skin and sinus signs of systemic disease
Tests
- Slit lamp exam by an ophthalmologist
- Blood count, CRP, ESR, kidney function, urinalysis
- Rheumatoid factor, anti-CCP, ANCA, ANA
- Syphilis and tuberculosis testing
- B-scan ultrasound for posterior scleritis
Treatment basics
- Urgent ophthalmology referral
- Oral NSAIDs such as naproxen for mild disease
- Oral prednisone for severe or necrotizing disease
- Immunosuppressants such as methotrexate or rituximab, with rheumatology
- Treat any infection first
Red flags
- Scleral thinning or a white patch without vessels (necrotizing scleritis)
- Vision loss
- Signs of vasculitis: blood in the urine, coughing blood, sinus disease
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.