Scleritis: symptoms, causes and treatment

According to Patient.info, scleritis causes redness of the eye that tends to come on more slowly than episcleritis. As the redness develops the eye becomes very painful, with a deep, boring kind of pain inside and around the eye. Sometimes the white of the eye has a bluish or purplish tinge. Vision may be blurred, the eye may be watery, although there is no discharge, and you may find light hard to tolerate.

Posterior scleritis, which affects the back of the eye, is rare and also painful, although the eye may not look red. Eye movements may be painful and there may be loss of vision.

The sclera is the firm white outer coat of the eye. Scleritis is inflammation of this layer and sometimes of the deeper tissues of the eye. Patient.info says it is much less common than episcleritis, causes a painful red eye and can affect vision, sometimes permanently, and that it can spread to affect the adjacent layers, including the episclera and the cornea.

It is a condition for an ophthalmologist to diagnose and manage. Unlike the mild redness of episcleritis, it is a medical priority because untreated inflammation can damage the structure of the eye.

Patient.info says management depends on the type of scleritis and its severity. The non-necrotising types are usually treated with oral non-steroidal anti-inflammatory medicines, and if these are not effective oral steroids are needed. Some doctors use injections of steroid into or around the sclera. If these treatments do not work, immunosuppressant drugs such as methotrexate and cyclophosphamide may be used, which can take several weeks to work, and biological agents such as rituximab can also be effective. Surgery is sometimes needed for complications.

Necrotising scleritis is treated with oral steroids and immunosuppressants as early as possible. Scleromalacia perforans does not respond well to treatment. Because some of these medicines suppress the immune system, your ophthalmologist will explain how you are monitored, and care may be shared with a rheumatologist when there is an underlying condition.

Patient.info says it is not known what triggers the inflammation. Both scleritis and episcleritis are more likely in people who have other inflammatory conditions, but this is particularly true of scleritis, which can occasionally be caused by infection with bacteria, viruses or, rarely, fungi. It names rheumatoid arthritis and systemic lupus erythematosus as associated conditions.

Scleritis affects about 4 people per 100,000 per year, a slightly older age group than episcleritis, usually in the fourth to sixth decades of life, and is slightly more common in women. Because of the link with systemic disease, the assessment may include questions about joint and other symptoms and tests for an underlying condition.

Patient.info says that if you develop scleritis you should be urgently referred to an eye specialist (ophthalmologist) and will usually be seen on the same day.

The NHS says to call 999 or go to A&E if you have a red eye and any changes to your sight, such as wavy lines, flashing or loss of vision, it hurts to look at light, you have a severe headache and feel sick, your eye or eyes are very dark red, you have injured your eye, or one pupil is bigger than the other. It says to ask for an urgent appointment with a GP or optician, or get help from NHS 111, if your eye is very painful and red or you wear contact lenses and have a red eye. Do not drive yourself to A&E.

Patient.info divides scleritis according to which part of the eye is involved and how inflamed the tissues are.

Patient.info lists the possible complications of scleritis as thinning of the sclera, glaucoma, cataract, raised intraocular pressure, retinal detachment and uveitis, many of which can permanently threaten sight and some of which need surgery.

The non-necrotising forms do not usually permanently affect vision unless the person goes on to develop uveitis, while necrotising scleritis with inflammation is the most severe and distressing form and vision is commonly permanently affected. When scleritis occurs with an underlying condition such as rheumatoid arthritis its progress tends to mirror that of the underlying disease. Support groups can help people who have had a similar experience.

On the NHS, suspected scleritis is referred urgently to an ophthalmology service, often via an eye casualty, and long-term treatment is shared with rheumatology when needed. Private ophthalmologists can assess promptly and prescribe the same first-line treatment, but ongoing immunosuppressant monitoring and any biological therapy are usually delivered through NHS hospital services in coordination with a rheumatologist. Whichever route you take, make sure a named clinician is responsible for follow-up.