Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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August 31, 2017
Scleritis
- Background:
- Scleritis is a vision-threatening condition.
- Etiology:
- 90% inflammatory
- Noninfectious
- Idiopathic
- Secondary to systemic diseases such as granulomatosis with polyangiitis, rheumatoid arthritis, or idiopathic orbital inflammatory disease (IOID)
- 7% infectious (often related to recent eye surgery or trauma)
- 90% inflammatory
- Diagnosis is usually made on history and clinical exam, with no need for imaging
- Imaging is useful when disease affects posterior sclera and is not directly seen on clinical exam
- Scleral enhancement is always abnormal (not to be confused with choroid enhancement, which is physiologic).
- Clinical Presentation:
- Ocular pain (most common)
- Blurred vision
- Periorbital cellulitis
- Key Diagnostic Features:
- Scleral thickening and enhancement
- Periscleral cellulitis (“ring” sign)
- Differential Diagnoses:
- Infection:
- Scleritis rarely only finding
- Associated findings such as adjacent sinus disease, soft-tissue abscess, significant soft-tissue stranding
- Uveitis:
- MRI able to distinguish uveitis from scleritis by showing thickening and enhancement of the choroid/retina complex (deep to the sclera), +/- subretinal effusions, and +/- retinal detachment
- Episcleritis:
- Redness of eye without tenderness
- Instillation of 10% phenylephrine will result in blanching of the superficial episcleral vessels with improvement of episcleritis, but no effect on scleritis
- Panophthalmitis/endophthalmitis:
- Diffuse, concentric thickening and enhancement of the sclera
- Peribulbar inflammation
- Idiopathic orbital inflammation with preferential scleral involvement:
- Similar presentation to scleritis
- Tumor (melanoma, lymphoma):
- Painless
- Less periscleral soft-tissue stranding on imaging
- Infection:
- Treatment:
- Topical steroids and/or topical NSAIDS
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