Compared to scleritis, episcleritis has minimal pain, is less commonly associated with systemic disease, and has a more benign, self-limiting course.
FIGURE 3-1. Episcleritis. A. This patient has episcleritis with a salmon pink hue. B. The figure on the right demonstrates the same eye with blanching of the episclera after 10% phenylephrine.
and all cases of necrotizing scleritis should be worked up.
TABLE 3-1. Scleritis Clinical Subtypes and Their Prevalence
TABLE 3-2. Systemic Disease Associations
Rheumatoid factor, anti-citrullinated cyclic protein, classical antineutrophil cytoplasmic antibody, protoplasmic-staining antineutrophil cytoplasmic antibody (p-ANCA), myeloperoxidase, antinuclear antibody (ANA), and antidouble stranded DNA, may be considered if an underlying rheumatologic disease is suspected.
Rule out treatable infectious causes such as syphilis and tuberculosis (RPR or VDRL, FTA-Abs or syphilis IgG, PPD, and QuantiFERON-TB Gold)
FIGURE 3-4. Scleritis. Diffuse anterior scleritis with inferotemporal thinning. Note the scleral injection and adjacent scleral thinning recognized by the blue color of the underlying choroid.
FIGURE 3-6. Necrotizing scleritis. Necrotizing scleritis in a patient with granulomatosis with polyangiitis with one suture remaining from a past scleral biopsy. Note the white, avascular patch of sclera with surrounding temporal thinning.
FIGURE 3-9. Posterior scleritis. Posterior scleritis causes disruption of the normal choroidal circulation as well as restriction of scleral outflow through the vortex veins. This causes subsequent dysfunction of the retinal pigment epithelium. A. This can result in a serous retinal detachment. Fluorescein angiography demonstrating (B) pinpoint choroidal leakage with (C) pooling of dye in the late frames. D. B-scan ultrasonography demonstrating thickening of the sclera and choroid (arrows) with edema of Tenon capsule behind the globe, which along with the optic nerve, creates the “T-sign.” (Courtesy William Benson, MD and Eliza Hoskins, MD.)
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