Eyes & Vision

Scleritis

Scleritis is severe inflammation of the sclera causing deep eye pain, a dark red or violaceous tender eye and possible visual loss; it is an ophthalmic emergency because necrotising or posterior disease can destroy the eye and may reveal systemic autoimmune, vasculitic or infectious disease.

In a nutshell

Scleritis is a serious, often autoimmune or vasculitic inflammation of the sclera: severe deep pain, a dark red/violaceous tender eye and possible visual loss. Anterior disease is visible; posterior disease may have severe pain with little external redness. It needs emergency ophthalmology assessment, systemic treatment and directed systemic/infectious work-up. Necrotising disease may be painless and can melt the globe.

Classic presentation

A patient with rheumatoid arthritis has deep eye pain waking them at night, a tender violaceous eye and blurred vision; slit-lamp examination shows deep scleral inflammation rather than benign episcleritis.

Key points

Severe deep pain, tenderness and dark red/violaceous scleral injection are the key warning pattern.
Scleritis is an ophthalmic emergency, usually needing assessment within 24 hours.
Posterior scleritis can have little anterior redness; use B-scan or other specialist imaging when suspected.
Necrotising scleritis may be painless and threatens scleral integrity and vision.
About a third have another inflammatory condition; rheumatoid arthritis and granulomatosis with polyangiitis are important associations.
Treatment is usually systemic and specialist-led; topical drops alone are inadequate for most scleral inflammation.
Exclude infection before escalating immunosuppression.

First-line investigation

Urgent slit-lamp/dilated ophthalmic assessment with visual function and pressure, plus B-scan or other imaging for posterior disease and directed systemic/infectious assessment.

Management

Emergency ophthalmology assessment

Refer suspected scleritis urgently, generally within 24 hours; admit or discuss immediately for visual loss, necrosis, posterior disease, corneal melt or systemic vasculitis/infection.^1,4,2

Define severity and exclude infection

Use slit lamp, visual function and pressure; image posterior disease with B-scan or MRI as required; assess for keratitis, uveitis, glaucoma, retinal disease, infection and systemic inflammation before immunosuppression.^2,1

Start systemic anti-inflammatory treatment

For non-necrotising non-infectious disease, ophthalmology may use an oral NSAID when safe; topical treatment is adjunctive and BNF/local prescribing rules govern risk and monitoring.^1,2,5

Treat necrotising or refractory disease aggressively

Necrotising, posterior, visually threatening or refractory scleritis may need high-dose systemic corticosteroid and steroid-sparing immunosuppression with ophthalmology/rheumatology input; treat systemic vasculitis or infection through the relevant team.^2,4,6

Monitor vision, scleral integrity and systemic disease

Review acuity, fields when relevant, inflammation, cornea, pressure and systemic symptoms; new pain, visual loss, blue-grey thinning or organ symptoms needs urgent reassessment.^2,3,4

Exam traps

Scleritis is severe and deep; episcleritis is usually mild and superficial.
A phenylephrine response may support the distinction but is not a safe stand-alone test or reason to delay referral.
Painless blue-grey scleral thinning can be necrotising scleritis/scleromalacia perforans.
Posterior scleritis may have a quiet-looking front of the eye.
Do not start immunosuppression for presumed autoimmune scleritis without considering infection.
A systemic screen is important even when there is no previously diagnosed rheumatological disease.

Illustrations

Scleral thinning after recurrent scleritisClose clinical photograph showing blue-grey scleral translucency from thinning after recurrent scleritis, with prominent superficial vessels. Label it as an example of structural damage and an ophthalmic emergency sign.Imrankabirhossain, Wikimedia Commons · CC-BY-SA-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.