AKT · Ophthalmology/Cornea & ant. segment

Scleritis

Inflammation of the sclera (often associated with systemic vasculitis/RA)

Overview

A painful, potentially sight-threatening inflammation of the sclera, frequently associated with systemic disease (rheumatoid arthritis, granulomatosis with polyangiitis, other vasculitides). Severe boring pain that wakes the patient, deep violaceous injection that does NOT blanch with topical phenylephrine. Needs systemic anti-inflammatory treatment.

Recognise

Severe, deep, boring ocular pain radiating to the brow/jaw that wakes the patient at night; tender globe
Deep violaceous/bluish scleral injection that does NOT blanch with phenylephrine (vessels are deep)
Necrotising scleritis (scleromalacia perforans, often RA) can perforate; ~50% have an underlying systemic disease

Red flags

Necrotising/posterior scleritis or visual loss → urgent ophthalmology + systemic immunosuppression
Scleritis + systemic features → investigate for vasculitis (GPA/RA)

Differentials & how to tell them apart

Episcleritismild/no pain, sectoral redness that BLANCHES with phenylephrine, self-limiting

Anterior uveitisphotophobia with AC cells and a small pupil, circumcorneal injection

Conjunctivitisdischarge, no significant pain, superficial injection

Scleritis — deep, violaceous scleral injection
Imrankabirhossain / CC BY-SA 4.0 — Wikimedia Commons

Investigations

Slit-lamp ± phenylephrine test (deep vessels do not blanch). Systemic work-up: RF/anti-CCP, ANCA, ANA, urinalysis; B-scan for posterior scleritis.

Management

Refer; systemic NSAID → oral steroid/immunosuppression per severity

1Urgent (within 24 h) ophthalmology referral. Mild non-necrotising disease: oral NSAID. Investigate for systemic vasculitis.Gate: Distinguish from episcleritis with the phenylephrine blanch test BEFORE labelling it benign — scleritis (deep vessels, severe pain) needs systemic treatment, episcleritis does not
2Inadequate response or necrotising/posterior disease → systemic corticosteroids and immunosuppression/biologics, co-managed with rheumatology.

Oral NSAID — mild non-necrotising anterior scleritis

Systemic corticosteroid — for inadequate NSAID response/severe disease — specialist

Immunosuppression/biologics — necrotising or vasculitis-associated disease (e.g. with rheumatology)

Key points

Severe boring pain that wakes you + non-blanching deep redness = scleritis (look for RA/vasculitis). Mild, blanching, comfortable = episcleritis.

Monitor & prognosis

Inflammation control; monitor the systemic disease.

Necrotising disease threatens the globe and signals serious systemic illness.

Source: College of Optometrists CMG; RCOphth; NICE CKS Red eye