Episcleritis
Simple episcleritis
Diagnosis
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Presentation : acute onset of redness and mild discomfort.
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Signs : hyperaemia may be sectoral (typically interpalpebral; Fig. 9.1A ) or diffuse.
Fig. 9.1
Episcleritis: (A) simple sectoral, (B) nodular.
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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Course : spontaneous improvement occurs within several days, but recurrences may occur.
Treatment:
not required if mild; otherwise lubricants or a weak steroid four times daily for 1–2 weeks.
Nodular episcleritis
Diagnosis
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Presentation : less acute onset than simple episcleritis with redness and discomfort worsening over 2–3 days.
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Signs : (a) one or more tender interpalpebral nodules ( Fig. 9.1B ) and (b) absence of deeper scleral thickening. After several attacks, the vessels surrounding the inflamed area may become permanently dilated.
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Course : more prolonged than simple episcleritis.
Treatment:
similar to that of simple episcleritis.
Immune-mediated scleritis
Anterior non-necrotizing scleritis
Definition:
scleritis is inflammation of the entire thickness of the sclera and results in oedema and cellular infiltration. It is much less common than episcleritis and ranges from a mild and self-limiting inflammation to a necrotizing sight-threatening condition.
Diagnosis
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Presentation : in 5th decade with redness, pain and aching.
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Diffuse disease : redness; generalized ( Fig. 9.2A ) or localized to one quadrant.
Fig. 9.2
Anterior non-necrotizing scleritis: (A) diffuse, (B) nodular.
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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Nodular disease : (a) single or multiple scleral nodules, of a deeper blue-red colour than episcleral nodules ( Fig. 9.2B ), (b) vascular congestion and dilatation with oedema and displacement of the entire beam of the slit lamp.
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Course : as inflammation settles, the affected area often takes on a slight grey/blue appearance due to increased translucency. Episodes recur over several years, with the frequency decreasing after approximately 18 months.
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Prognosis : usually good, although more than 10% of patients with nodular scleritis develop necrotizing disease if early treatment is not instituted.
Anterior necrotizing scleritis with inflammation
Definition:
aggressive form of scleritis, bilateral in 60%, which may result in severe visual morbidity unless appropriately treated.
Diagnosis
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Presentation : later than in non-necrotizing scleritis with the gradual onset of pain that becomes severe and radiating, often interfering with sleep and responding poorly to analgesia.
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Vaso-occlusive type : often associated with rheumatoid arthritis; (a) starts as isolated patches of scleral oedema with overlying nonperfused episclera and conjunctiva, (b) may progress to scleral necrosis ( Fig. 9.3A ).
