Sclérite | Clinique Omicron Québec
Classification and clinical forms
- Diffuse anterior scleritis : the most frequent form (40 % of scleritis) + diffuse erythema + purplish over the entire anterior face + moderate to severe pain + sclerotic edema + good response to oral NSAIDs
- Nodular anterior scleritis : single or multiple sclerotic nodule(s) + dark red + firm + immobile (distinguished from nodular episcleritis, in which the nodule is mobile) + marked pain + response to NSAIDs but often requires corticosteroids
- Necrotizing anterior scleritis with inflammation : the most severe and destructive form + areas of scleral ischemia + necrosis + thinning + very intense pain + almost constant association with severe systemic disease (GPA + severe erosive RA) + systemic corticosteroids + mandatory immunosuppressants (cyclophosphamide + methotrexate + rituximab)
- Perforating scleromalacia (necrotizing scleritis without inflammation): progressive, painless sclerotic thinning (paradox) + uvea visible under thinned sclera (blue-grey tint) + associated with long-standing, severe RA + risk of perforation at the slightest trauma + no proven effective treatment + surgery if perforation imminent
- Posterior scleritis : rare + difficult to diagnose (not visible to the naked eye) + deep eye pain + periorbital headache + visual impairment + proptosis + restricted eye movements + exophthalmos + B-echo (T-sign - perisclerotic fluid + posterior sclerotic thickening) + orbital MRI + associated with autoimmune diseases + treatment: systemic corticosteroids ++ + immunosuppressants
Scleritis vs. episcleritis - key clinical distinction
| Criteria | Sclerite | Episclerite |
|---|---|---|
| Affected layer | Sclera (deep layer) | Episclera (surface layer between conjunctiva and sclera) |
| Pain | Deep + intense + nocturnal + radiating to forehead/jaw | Mild + discomfort + no deep pain + or no pain at all |
| Eye color | Purplish red + bluish (deep dilated vessels) | Bright red (superficial episcleral vessels) |
| Phenylephrine test 10 % | NO whitening → deep vessels (unreachable) | Whitening in 10-15 min → superficial vessels (vasoconstricted) |
| Nodule (if present) | Immobile + adherent to the sclera | Mobile + moves with conjunctive |
| Systemic disease | Associated in 40-50 % of cases → systematic assessment | Associated in 30 % of cases → assessment if recurrent |
| Risk of complications | High (perforation + loss of globe) | Low + frequent spontaneous resolution |
| Treatment | Oral NSAIDs + systemic corticosteroids + immunosuppressants depending on form | Artificial tears + topical NSAIDs ± short-acting oral NSAIDs |
Systematic etiological workup
- Basic balance : CBC + ESR + CRP + creatinine + ionogram + liver function tests + proteinuria + urine sediment (hematic cylinders → vasculitis) + chest X-ray
- Autoimmune test : ANA + anti-native DNA + ANCA (c-ANCA/anti-PR3 → GPA + p-ANCA/anti-MPO → PAM) + RF (rheumatoid factor) + anti-CCP (RA) + complement C3 + C4 + CH50 (lupus) + cryoglobulins + HLAB27 (SpA)
- Infectious diseases : QuantiFERON-TB Gold (tuberculosis) + syphilis serology (TPHA + VDRL) + HIV serology + VZV serology if suggestive context
- Imaging : thoracic HRCT scan if GPA or suspected sarcoidosis + orbital MRI if posterior scleritis
Treatment
- Oral NSAIDs (mild to moderate forms - diffuse or nodular scleritis) : ibuprofen 400-600 mg × 3/day + or flurbiprofen (Froben®) 100 mg × 3/day + or indomethacin 25-50 mg × 3/day × 4-6 weeks + with gastric protection (PPI) + effective in 60-70 % of non-necrotizing forms
- Systemic corticosteroids (severe + necrotizing + posterior forms) : prednisone 1 mg/kg/day × 4-6 weeks + gradual decrease + methylprednisolone IV 1 g/day × 3 days if very severe form (bolus) before oral relay + never use topical corticoids alone (ineffective on scleritis - layer too deep)
- Immunosuppressants (necrotizing scleritis + severe systemic disease) : methotrexate 15-25 mg/week (RA + sarcoidosis) + cyclophosphamide IV (GPA + PAM + severe vasculitis) + rituximab (refractory GPA + severe RA) + mycophenolate mofetil (lupus) + treatment of causative systemic disease as a priority
- Infectious scleritis: antivirals (aciclovir + valaciclovir for VZV) + antituberculosis drugs if tuberculosis + penicillin G if syphilis → never treat scleritis empirically with corticosteroids alone without first ruling out infection (risk of worsening infection)
- Surgical treatment (perforating scleromalacia + perforation) : scleral patch (connective tissue graft + fascia + donor sclera) + vitrectomy if endocular complications + complex surgery + variable results
Consult an ophthalmologist urgently within 24-48 hours if a purplish-red eye appears + painful + with deep pain radiating to the forehead or jaw - these signs distinguish scleritis from simple conjunctivitis or episcleritis, and require ophthalmological management and systemic assessment without delay. Necrotizing or posterior scleritis is a strict ophthalmological emergency. For rapid referral to ophthalmology and initiation of an etiological workup (ANCA + FR + ANA + QuantiFERON), Clinique Omicron offers consultations at its points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's specialized physicians and nurse practitioners (NPs) distinguish scleritis from episcleritis and conjunctivitis on clinical examination, immediately refer any confirmed scleritis to ophthalmology, initiate a systematic etiological workup (autoimmune + infectious + ANCA), prescribe oral NSAIDs for mild forms while awaiting specialized evaluation, and coordinate with rheumatology and internal medicine for treatment of underlying systemic disease. Consultations are available at several points of service in Quebec, and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The contents of this page are provided for information purposes only and do not replace the advice of an ophthalmologist. Scleritis is a relative ophthalmological emergency requiring rapid specialist management to prevent serious complications (perforation + loss of globe). Never use topical corticoids alone in scleritis - they are insufficient to treat deep scleral inflammation.
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