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Medical Disclaimer: This information is for educational purposes only and is not a substitute for professional medical advice.
Medical Information & Treatment Guide
Scleritis (ICD-10: H15.0) is a severe, potentially sight-threatening inflammation of the sclera, the eye's tough outer wall. This clinical guide explores its systemic associations and advanced treatment protocols.
Prevalence
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Common Drug Classes
Clinical information guide
Scleritis is a severe, chronic, and potentially blinding inflammatory disease that affects the sclera—the white, opaque, fibrous outer layer of the eyeball. Unlike episcleritis (inflammation of the more superficial layer), scleritis involves the deep vascular plexus and the collagenous tissue of the sclera itself. Pathophysiologically, it is characterized by immune-mediated destruction of the scleral tissue, often involving a Type III (immune complex-mediated) or Type IV (delayed-type) hypersensitivity reaction. At a cellular level, inflammatory cells like T-lymphocytes and macrophages infiltrate the scleral stroma, releasing cytokines and proteases that can lead to tissue thinning, necrosis, and in severe cases, perforation of the globe (melting).
Scleritis is considered a relatively rare condition. According to epidemiological data published in the Journal of Ophthalmic & Vision Research (2021), the estimated incidence is approximately 3.4 to 4.1 cases per 100,000 person-years. It most frequently occurs in adults between the ages of 40 and 60, with a significant predilection for women, who account for approximately 60% to 70% of cases. Research indicates that up to 50% of patients with scleritis have an underlying systemic autoimmune or infectious disease, making it a critical diagnostic marker for internal health issues.
Scleritis is primarily classified based on the anatomical location of the inflammation, using the Watson and Hayreh system:
The impact of scleritis on quality of life is profound. The pain associated with the condition is often described as 'boring' or 'lancinating,' frequently waking patients from sleep and requiring high doses of analgesics. Beyond the physical pain, the risk of permanent vision loss creates significant psychological distress. Patients may find it difficult to work in environments with bright lights, perform tasks requiring fine visual focus, or maintain social commitments due to the debilitating nature of the flare-ups and the side effects of systemic immunosuppressive medications.
Detailed information about Scleritis
The earliest indicator of scleritis is typically a deep, aching discomfort in the eye that may initially be mistaken for a tension headache or sinus pressure. Unlike common 'red eye' (conjunctivitis), the redness in scleritis often has a distinct violaceous (bluish-purple) hue, which is most visible in natural daylight. This color change indicates involvement of the deep episcleral vascular plexus.
Answers based on medical literature
Scleritis is generally considered a chronic condition that is manageable rather than 'curable' in the traditional sense. While the acute inflammation can be successfully put into remission with medications, the underlying immune dysregulation often remains. For many patients, long-term maintenance therapy is required to prevent flares and protect vision. If the scleritis is caused by an infection, it may be cured with appropriate antimicrobial treatment. However, for the majority of autoimmune-related cases, the goal is long-term suppression of the disease.
Yes, if left untreated, scleritis can lead to permanent blindness through several mechanisms. The inflammation can cause the sclera to thin and eventually perforate, or it can lead to secondary complications like glaucoma, retinal detachment, or optic nerve damage. Necrotizing scleritis is the most dangerous form and carries the highest risk of vision loss. However, with modern immunosuppressive therapies and early intervention, the majority of patients are able to preserve their sight. Regular monitoring by an ophthalmologist is the best defense against vision loss.
This page is for informational purposes only and does not replace medical advice. For treatment of Scleritis, consult with a qualified healthcare professional.
In cases of posterior scleritis, patients may experience double vision (diplopia) due to inflammation affecting the extraocular muscles, or a feeling of the eye being pushed forward (proptosis). Some may also notice 'floaters' or a change in their color perception if the optic nerve is involved.
In the early stages, symptoms may be limited to localized redness and mild aching. As the disease progresses to a necrotizing stage, the pain becomes unbearable, and the sclera may take on a translucent appearance, allowing the underlying dark uveal tissue to become visible. In scleromalacia perforans, the lack of pain can be deceptive, as the tissue is silently thinning toward perforation.
> Important: Scleritis is a medical emergency. Seek immediate ophthalmological evaluation if you experience:
> * Sudden, severe eye pain that prevents sleep.
While the core symptoms remain consistent, older patients—particularly those with long-standing Rheumatoid Arthritis—are more likely to develop the necrotizing, non-inflammatory form (Scleromalacia Perforans). Younger patients are more likely to present with idiopathic (unknown cause) diffuse anterior scleritis, which often responds more readily to initial treatment.
Scleritis is primarily an immune-mediated inflammatory disorder. In approximately 50% of cases, it is the ocular manifestation of a systemic autoimmune disease. Research published in Ophthalmology (2022) suggests that the underlying mechanism involves the deposition of circulating immune complexes in the scleral vessels, which triggers an inflammatory cascade. This leads to the recruitment of neutrophils and macrophages that release matrix metalloproteinases (MMPs), enzymes that break down the scleral collagen.
Individuals with established systemic vasculitis or connective tissue diseases are at the highest risk. According to the American Academy of Ophthalmology, approximately 1 in 4 patients with necrotizing scleritis may have an undiagnosed systemic vasculitis at the time of presentation. Common associated conditions include:
Because most cases are autoimmune in nature, primary prevention is difficult. However, secondary prevention—preventing flares and complications—is possible through rigorous management of underlying systemic diseases. Early screening for ocular symptoms in patients with known autoimmune disorders is highly recommended by clinical guidelines.
The diagnostic journey typically begins with a comprehensive eye examination by an ophthalmologist. Because scleritis can be a sign of a life-threatening systemic disease, the diagnosis often involves a multidisciplinary team, including rheumatologists.
The physician will perform a slit-lamp examination to visualize the depth of the inflammation. A key diagnostic step is the Phenylephrine Test: the doctor applies 2.5% or 10% phenylephrine drops to the eye. In episcleritis (a milder condition), the surface blood vessels will 'blanch' or turn white. In scleritis, the deep vessels do not blanch, confirming the diagnosis.
Diagnosis is primarily clinical, based on the presence of deep scleral edema, the characteristic violaceous hue, and the failure of vessels to blanch with phenylephrine. The Watson-Hayreh classification is used to grade the severity and type.
It is vital to distinguish scleritis from:
The primary goals of scleritis treatment are to alleviate pain, suppress inflammation, and prevent the destruction of the ocular globe. Successful treatment is measured by the resolution of scleral edema and the stabilization of any underlying systemic disease.
For non-necrotizing anterior scleritis, the standard initial approach involves systemic therapy. Unlike episcleritis, topical drops are rarely sufficient because they do not penetrate the sclera effectively. According to the Preferred Practice Patterns of major ophthalmological societies, systemic non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line choice for mild to moderate cases.
If a patient does not respond to corticosteroids, a combination of a DMARD and a biologic may be considered. In cases of infectious scleritis, targeted antimicrobial therapy (antibiotics, antivirals, or antifungals) is mandatory before or alongside cautious steroid use.
Treatment is often long-term, lasting months or even years. Patients require regular monitoring of intraocular pressure, lens clarity, and systemic blood work to check for medication toxicity.
> Important: Talk to your healthcare provider about which approach is right for you.
While diet alone cannot cure scleritis, an anti-inflammatory dietary pattern may support overall immune health. Research in the American Journal of Clinical Nutrition suggests that the Mediterranean diet—rich in omega-3 fatty acids (from fatty fish), antioxidants (from colorful vegetables), and polyphenols—can help modulate systemic inflammation. Reducing the intake of ultra-processed foods and refined sugars is generally recommended for patients on long-term corticosteroids to manage blood sugar levels.
During an active scleritis flare, high-impact exercise or activities that increase intraocular pressure (like heavy weightlifting or inverted yoga poses) should be avoided. Once the inflammation is controlled, regular moderate exercise is encouraged to combat the bone-thinning and weight-gain side effects of corticosteroid therapy.
Scleritis pain often worsens at night. Maintaining a consistent sleep schedule and using extra pillows to keep the head slightly elevated may help reduce ocular congestion. Darkened rooms and cool compresses (if tolerated) can provide symptomatic relief during the day.
Chronic pain and the fear of vision loss are significant stressors. Evidence-based techniques such as Mindfulness-Based Stress Reduction (MBSR) and cognitive-behavioral therapy (CBT) have been shown to improve pain tolerance and quality of life in patients with chronic inflammatory conditions.
Caregivers should monitor the patient for signs of depression or anxiety. Helping with the administration of complex medication schedules and providing transportation to frequent follow-up appointments is crucial, especially if the patient's vision is temporarily impaired.
The outlook for scleritis varies significantly based on the type and the presence of underlying disease. According to a long-term study published in British Journal of Ophthalmology, over 80% of patients with non-necrotizing scleritis maintain good vision with appropriate treatment. However, necrotizing scleritis carries a more guarded prognosis, with a higher risk of permanent visual impairment.
If left untreated or poorly managed, scleritis can lead to:
Management is typically a marathon, not a sprint. Patients often require 'maintenance' doses of immunosuppressants to prevent relapses. Regular eye exams every 3 to 6 months are standard even during periods of remission.
Patients are encouraged to join support groups (such as those for Rheumatoid Arthritis or Vasculitis) to share experiences. Protecting the eyes from UV light and wind can reduce secondary irritation.
Contact your ophthalmologist immediately if you notice a return of the 'deep ache,' a change in the color of the white of your eye, or if you experience new side effects from your medications, such as unusual bruising or persistent thirst.
Scleritis is significantly more severe than 'pink eye' (conjunctivitis). While pink eye affects the clear membrane over the eye and causes itching, burning, and discharge, scleritis affects the deep structural wall of the eye. The pain in scleritis is a deep, boring ache that often radiates to the head, whereas pink eye is usually just uncomfortable. Furthermore, scleritis does not typically cause the crusting or discharge seen in conjunctivitis. Scleritis is a sight-threatening emergency, while most cases of pink eye are self-limiting or easily treated with topical drops.
Scleritis itself is not directly hereditary, meaning you do not 'inherit' the condition from a parent. However, the predisposition toward autoimmune diseases that cause scleritis, such as Rheumatoid Arthritis or Lupus, can run in families. Certain genetic markers, like HLA-B27, are known to increase the risk of developing various inflammatory eye conditions. If you have a family history of autoimmune disorders, you may be at a slightly higher risk. Most cases, however, occur sporadically without a clear family link.
It is generally advised to stop wearing contact lenses during an active flare of scleritis. Contact lenses can irritate the ocular surface and increase the risk of secondary bacterial infections, which can be devastating when the eye is already inflamed. Additionally, the medications used to treat scleritis, including various eye drops, may interact with lens materials. Once the inflammation is completely resolved and your ophthalmologist gives the clear, you may be able to resume lens wear. However, many patients find that their eyes remain more sensitive even after the flare has passed.
While there is no specific 'scleritis diet,' systemic inflammation is heavily influenced by nutritional choices. Diets high in refined sugars and trans fats can promote a pro-inflammatory state in the body, potentially triggering flares in susceptible individuals. Conversely, an anti-inflammatory diet rich in omega-3 fatty acids and antioxidants may help support the immune system. Patients on long-term steroids must also be careful with salt and sugar intake to manage side effects like hypertension and weight gain. Always discuss major dietary changes with your medical team.
During an active, painful flare, it is best to limit exercise to light walking and avoid strenuous activity. Intense physical exertion can increase blood flow and pressure to the head, which may worsen the throbbing pain of scleritis. Specifically, you should avoid any activities that involve bending over or heavy lifting, as these can spike intraocular pressure. Once the condition is stabilized with medication, exercise is actually encouraged. It helps mitigate the side effects of systemic steroids, such as bone density loss and weight gain.
The duration of a scleritis flare is highly variable and depends on how quickly treatment is initiated. With aggressive systemic therapy, the acute pain may begin to subside within days, but the visible inflammation often takes several weeks to resolve. Many patients require a slow 'taper' of medications over several months to ensure the inflammation does not return. In some cases, scleritis becomes a chronic, low-grade issue that requires years of management. Early diagnosis is the most significant factor in shortening the duration of a flare.
Stress is a well-known trigger for many autoimmune conditions, and scleritis is no exception. High levels of cortisol and other stress hormones can dysregulate the immune system, potentially leading to an inflammatory flare-up. Many patients report that their symptoms worsen during periods of significant life stress or emotional upheaval. While stress management alone cannot treat scleritis, techniques like meditation and adequate sleep are important components of a holistic treatment plan. Reducing stress can help improve the body's response to medical therapies.
Scleritis is extremely rare in children and is much more common in middle-aged adults. When it does occur in pediatric populations, it is almost always associated with a systemic condition like Juvenile Idiopathic Arthritis (JIA) or an infection. Pediatric scleritis requires an immediate and thorough systemic workup by both a pediatric ophthalmologist and a rheumatologist. The treatment approach in children is particularly delicate due to the potential impact of long-term steroid use on growth and development. Fortunately, most childhood eye inflammation is the more superficial episcleritis or uveitis.
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