Sclerite

Scleritis is an inflammation of the scleral, or outer covering of the eye. It often occurs in women. In children, it is rarely diagnosed, but in childhood it takes a very painful form. Leave the disease untreated, because it can spread to the conjunctiva and cornea. There is a risk of partial or complete loss of vision.

The sclera is the white membrane of the eyeball. It is also called the outer, scleral, or just the whites of the eye. It performs supportive and protective functions: serves as a support for the internal structures of the eye and protects them from the factors of the external environment. The sclera has an average thickness of 0.3-1 mm. In children it is very thin. A pigment may be seen through it, which gives the sclera a bluish tint. In childhood, this part of the eye is more vulnerable than in adults. Even a small inflammation leads to severe discomfort.

Scleritis is an ophthalmologic pathology of an inflammatory nature. It is characterized by a slowly progressing course. In 73% of cases it is diagnosed in women between the ages of 34-56. In men it is observed 1.6 times, and in children – 2 times less frequently.

The outer shell consists of several layers. The danger of scleritis is that it affects the sclera entirely. In addition, there is a risk of inflammation spreading to the neighboring eyeball membranes: vascular, mucosa, iris and cornea. If the disease affects these structures, the person’s vision gets worse. If the course of the disease is too severe and there is no treatment, the patient may go blind.

Causes of scleritis

Scleritis in children and adults occurs mainly due to the appearance of antibodies in the eye, which the body secretes to fight certain systemic diseases. These can be considered disabling factors for scleritis. These diseases include:

• Rheumatoid arthritis.
• Sarcoidosis.
• Wegener’s granulomatosis.
• Recurrent polychondritis.
• Systemic lupus erythematosus.

The following causes may also provoke scleritis:

• Bacteria and fungi: Staphylococcus aureus, Pseudomonas aeruginosa.
• Viruses: herpes, adenovirus.
• Mechanical trauma to the eyeball.
• Taking anti-tumor medications.
• Chemical substances getting into the eye.
• Problems with the thyroid gland.
• Changes in the hormonal background.
• Radioactive radiation.

There is also such a concept as “post-surgical scleritis” when after surgical treatment of any ophthalmic pathology an inflammatory process develops on the sclera.

People with diabetes, tuberculosis and syphilis are more vulnerable to this disease. But in children, scleritis occurs mainly due to trauma or poor hygiene, which causes infection of the eye.

Scleritis symptoms

In scleritis, the symptoms may vary depending on the type of scleritis. But there are common signs that are common to all forms of the disease. At first, the sclera becomes red and painful. Gradually they intensify, especially when moving the eyeballs. The pain involves not only the eyes, but also the brow arches, forehead, and jaw. Painkillers do not help much.

If scleritis develops in a young child who cannot complain about his condition, he cries all the time, refuses to eat and hardly sleeps. You can pay attention to other signs, such as swelling of the eyelids and conjunctiva. Ptosis may occur in some patients because of this. If the eye is examined under an ophthalmoscope, local edemas may be seen between the equator of the eyeball and the limbus. They have a dark purple color.

Vision with scleritis does not always deteriorate. It usually occurs when the inflammatory process spreads from the sclera to the surrounding tissue, and also in case of complications with the cornea.

A number of symptoms are observed almost always. These include:

• Increased photosensitivity.
• Constant lacrimation.
• Increased intraocular pressure.
• Bulging of the eye – exophthalmus.
• A grayish tint to the sclera due to its thinning.
• Overflow of blood vessels under the mucosa.
• A sensation of a foreign body.

But these signs do not appear immediately, but as the disease progresses.

Classification of scleritis

Scleritis is classified on various grounds. Each type is characterized by its own specific symptoms. According to the form of the course are distinguished:

Acute scleritis. Develops very quickly with a large number of signs, gives a strong discomfort to the patient. As the disease progresses, the inflammatory process involves, vessels, conjunctiva and other tissues.
Chronic scleritis. Appears less frequently than acute, and is characterized by moderate symptoms. Sometimes symptoms disappear for a long time, but reappear after a while.

According to the localization of inflammation, there are posterior and anterior scleritis. The first one is the rarest. It occurs in only 2% of patients. The pathological focus is located behind the scleral membrane, in its deepest layers. At the initial stage the disease has no manifestations. This is where its danger lies. Scleritis progresses and spreads from the white membrane to other structures. If the stage is neglected, it may cause retinal detachment and edema of the optic nerve. There is a risk of visual impairment and even complete loss of vision.

Varieties of anterior scleritis

Anterior scleritis is registered much more frequently – in almost 98% of patients. It begins with redness of the sclera, which becomes visible at an early stage. Then one of two types of pathology may develop: necrotizing and non-crotizing. The first can be with or without inflammation. Necrotizing scleritis without inflammation manifests itself in the following symptoms:

• Yellowish spots on the sclera that gradually increase in size and merge.
• Thinning of the white membrane, which causes the vessels in the eye to become translucent.
• Staphyloma formation – protrusion of the posterior part of the sclera with its possible perforation if ophthalmotonus is increased.

The necrotizing form with an inflammatory process is considered the most complicated and dangerous. It becomes bilateral, i.e. both eyes are affected. It is known that most patients with this type of scleritis have problems of a cardiovascular nature. The main symptoms of necrotizing inflammation of the sclera:

• Hyperemia of parts of the scleral membrane.
• Increasing pain that cannot be relieved by analgesics.
• Pain involving the eyes, eyebrows, jaw, and forehead.
• Decreased conductance of the sclera vessels.
• Abnormal tortuosity of the vascular meshwork.
• Formations of avascular zones with poor blood circulation.
• Tissue necrosis, the zone of which gradually increases.

An increase in intraocular pressure leads to a bulging of the posterior wall of the sclera. With glaucoma, cataract, and macular pathologies, the disease becomes more complicated. The risk of blindness increases dramatically.

Necrotizing scleritis can be diffuse or nodular. The first is characterized by edema and marked vasodilation. The inflammation involves the whole anterior part of the sclera. Nodular scleritis can be distinguished by small reddish nodules which appear on the sclera. At the initial stage, they may not be felt or accompanied by pain.

The difference from episcleritis

Sometimes one of the varieties of scleritis include episcleritis – inflammation of the episcleral membrane – one of the layers of the outer layer. But this pathology is not so dangerous. In most cases, it passes without treatment. At episcleritis can also appear nodules. Their distinctive feature is their migratory nature. They move along with the conjunctiva. This is not the case with scleritis.

Types of scleritis according to the extent of inflammation

The disease under consideration can be unilateral and bilateral. In the first case, the inflammation covers the left or right eye. It usually occurs due to mechanical trauma or tissue infection. In bilateral scleritis, both eyeballs are affected.

Types of scleritis according to etiology

Based on the causes, scleritis is divided into several other varieties:

• Rheumatic: as a consequence of rheumatism.
• Infectious: viral, fungal or bacterial.
• Traumatic: with or without foreign body penetration.
• Postoperative: after surgical treatment of the eye.
• Idiopathic: of unknown etiology (30% of cases).

Sometimes purulent scleritis is distinguished separately, in which exudate with purulent content is discharged from the eye. It is usually caused by microbes deposited on the sclera from other structures of the eyeball, from the nose or from the external environment.

Of all the above varieties, anterior nodular scleritis usually occurs in children. We are talking about newborns whose immune system is very weak. The disease first appears as a small dot on the scleral membrane. After a while another one appears and so on. The baby is in severe pain, so he is constantly crying, refuses to breastfeed and does not sleep. All these symptoms are alarming for the mother.

Degrees of severity of scleritis

Scleritis can progress slowly or rapidly, depending on the etiology and form of the course. But it is possible to distinguish the stages of the disease, which any of its varieties passes:

• Light. Visually manifested only by redness of the sclera. The disease does not cause discomfort.
• Medium. There are painful sensations in the eyes, lacrimation, a person complains of headache and fatigue.
• Severe. Vision problems are observed. Soreness becomes pronounced when palpating and moving the eyeballs. At this stage, the inflammatory process spreads to almost the entire outer membrane.

The disease usually reaches the last stage if scleritis is not treated at all or if there are concomitant eye and systemic diseases.

How to distinguish scleritis from other ophthalmopathologies

Symptoms of scleritis can be confused with signs of iritis, keratitis, conjunctivitis, and blepharoconjunctivitis. To differentiate sclera inflammation from other eye diseases is as follows:

• In scleritis, there is pain on palpation. The other diseases may be accompanied by pain, but not with pressure.
• Eye redness in iritis and keratitis is concentrated around the iris, and in sclera lesions, in any part of it.
• In blepharoconjunctivitis and conjunctivitis, the eyes and eyelids turn red on the inside which is not the case in scleritis.
• Visual acuity usually does not decrease with inflammation of the conjunctiva and eyelid margins. An inflammatory process involving the outer membrane will lead to a decrease in visual function, although not immediately.

But only a doctor can make an accurate diagnosis. The symptoms of scleritis, such as lacrimation, reddening of the sclera, pain are also typical for an ordinary eyeball injury. Therefore, self-treatment is contraindicated. It is even more advisable to consult an ophthalmologist if the above mentioned symptoms are observed in a child. It will reflexively rub its eyes, which may lead to the infection getting into them. It will take longer to treat the disease.

It is common for people with scleritis to have another disease, like rheumatoid arthritis or other autoimmune disease. 

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Diagnosis of scleritis

First you need to show your baby to an ophthalmologist. If it is necessary to clarify the systemic pathology that may have caused the scleritis, he will give a referral to other specialists. During the initial consultation, the ophthalmologist will conduct a physical and instrumental examination. It is necessary to differentiate the disease from other diseases, determine its etiology, degree, nature of spread, etc. The patient needs to undergo a series of ophthalmologic procedures:

• Ophthalmoscopy – examination of the eye fundus.
• Tonometry – measurement of intraocular pressure.
• Fluorescence angiography – examination of the condition of blood vessels using a special dye.
• Visometry – determination of visual acuity.
• Biomicroscopy – examination of the internal structures of the eye with a slit lamp.
• Perimetry – assessment of the fields of vision.

If necessary, a CT scan, ultrasound, MRI, echography, blood and urine tests, immunological and allergic tests, as well as bacteriological and virological studies, and conjunctival scraping are prescribed. The results are used to make a diagnosis and prescribe a treatment.

Scleritis treatment

How and what to treat scleritis depends on its causes and type. Treatment may include medication therapy, physical procedures and surgery. Based on the condition of the patient, his age and medical indications, the doctor prescribes the following types of medications:

• Steroid drops and ointments, which quickly eliminate inflammation. They can increase eye pressure, so hypotensive solutions are additionally prescribed. Scleritis in children is rarely treated with steroids because they cause side effects.
• Drops based on enzymes that promote the resorption of inflammation foci.
• Pain pills that have an anti-inflammatory effect.
• Solutions with narcotic substances for instillation into the eye. Used when there is very severe pain that cannot be treated with regular analgesics.
• Antibiotics and antibacterial drops used in cases where a bacterial infection has joined the scleritis. If the course is very severe, injections with antibiotics are placed under the conjunctiva.

If your baby has scleritis, you can not take him out in the open sun. Putting sunglasses on your child is difficult, so you need to provide other means of protection – a hat or a closed stroller. You can not hold a child’s head down or tilt it. In such a position, the pressure on the sclera increases. It thins and may rupture.

The disorder causing scleritis may be serious. However, it may not be discovered the first time you have the problem. The outcome will depend on the specific disorder.

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Physical therapy treatment for scleritis

If drug therapy does not help, the disease is delayed or complicated by other pathologies, physical therapy is prescribed:

• Electrophoresis of antibiotics or with calcium chloride.
• Ultraviolet irradiation.
• Beta therapy – radiation.
• Dyadinamotherapy – exposure to electric current.

In some cases, massage of the eyeballs is practiced. Not all of these treatments for scleritis are appropriate for infants. But they are used to treat schoolchildren and adult patients. It is not recommended to treat the disease with folk remedies. If necessary, the doctor himself will prescribe a specific recipe.

Surgical treatment of scleritis

Surgery may be required if the sclera and other membranes of the eye are seriously affected, if there are perforations, retinal detachment, corneal or iris deformities. Surgical treatment of scleritis is also necessary for abscesses. Medical indications determine the type of procedure. Laser photocoagulation may be performed. If the scleral or corneal membrane is severely thinning, donor material transplantation is required.

Prognosis and complications

Everything depends on the type of scleritis. It often heals quickly, but only if you see a doctor in time. If the visit is delayed or the recommendations are not followed, complications may arise:

• keratitis;
• iridocyclitis;
• Thinning of the sclera;
• secondary glaucoma;
• retinal detachment;
• corneal clouding;
• eye deformity;
• endophthalmitis;
• Panophthalmitis.

Some of these pathologies can cause blindness. The last two are the most dangerous. They can cause the patient to die.

Prevention

Specific prevention of scleritis is not developed, especially for children. It is necessary to strengthen immunity, carefully monitor hygiene, and treat all diseases in time. Newborn children should be under almost constant medical supervision, including an ophthalmologist. Closely monitor the baby, its condition, appetite and sleep. Show the doctor if there are any warning signs.