The sclera is the dense, white, protective outer layer that forms the majority of the eyeball. When this robust layer becomes inflamed, the condition is known as scleritis. Anterior scleritis refers to inflammation affecting the front portion of the sclera. This condition can cause pain and eye redness, sometimes leading to vision problems if left unaddressed.
Recognizing the Signs
Individuals experiencing anterior scleritis often report severe eye pain that can radiate to the forehead, brow, jaw, or sinuses. This pain often worsens at night and may awaken a person from sleep. The white part of the eye exhibits redness and swelling, often presenting with a distinct bluish-red or violaceous hue. This redness can be localized to one section or spread across the entire sclera.
Other common symptoms include increased tearing and extreme sensitivity to light, known as photophobia. Anterior scleritis is further categorized into three main types based on their appearance. Diffuse scleritis involves widespread inflammation across the sclera, making it the most common form. Nodular scleritis is characterized by the presence of firm, immovable, and tender bumps or nodules on the sclera.
The most severe form is necrotizing scleritis, which involves intense pain and significant destruction of scleral tissue, potentially leading to thinning of the eye wall. A rare subtype, scleromalacia perforans, is a necrotizing form that can occur without pain or redness, yet still causes severe tissue thinning. These distinct presentations guide the initial assessment of the condition’s severity.
Associated Systemic Conditions
Anterior scleritis is often a manifestation of an underlying inflammatory condition, rather than an isolated eye issue. Approximately 50% of scleritis cases are linked to a systemic disease, most often an autoimmune disorder. These conditions involve the immune system mistakenly attacking healthy tissues throughout the body.
Common autoimmune diseases associated with scleritis include rheumatoid arthritis and systemic lupus erythematosus. Other links exist with granulomatosis with polyangiitis, inflammatory bowel disease, and sarcoidosis. Occasionally, scleritis can also stem from an infection, such as viral, bacterial, or fungal pathogens, or from previous eye trauma. In some instances, despite thorough investigation, no specific cause is identified, classifying the condition as idiopathic.
The Diagnostic Process
Diagnosis of anterior scleritis involves a thorough eye examination by an ophthalmologist. A primary diagnostic tool is the slit-lamp microscope, allowing the doctor to view eye structures under high magnification and observe deep scleral vessels. During this examination, the eye may be gently touched to check for tenderness, a specific sign of scleritis.
A key step in differentiating scleritis from less severe conditions like episcleritis is the use of phenylephrine eye drops. These drops constrict superficial blood vessels; in episcleritis, the redness will blanch or disappear, while in scleritis, the deeper inflamed vessels remain visibly red, confirming the diagnosis. If an underlying systemic condition is suspected, the diagnostic process includes a referral to a rheumatologist and laboratory tests, such as blood work to identify inflammatory markers or specific antibodies.
Managing and Treating Anterior Scleritis
Treatment for anterior scleritis aims to reduce inflammation, manage pain, and address any underlying systemic disease to prevent complications like vision loss. Treatment approach depends on the severity and type of scleritis. For milder diffuse or nodular anterior scleritis, oral nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial therapy.
If NSAIDs do not control inflammation or for more significant cases, oral corticosteroids like prednisone are prescribed. These medications suppress the body’s immune response to reduce swelling and pain. For severe, recurrent, or necrotizing scleritis, or when an underlying autoimmune disease is present, stronger immunosuppressive drugs or biologic therapies may be necessary. These agents specifically target components of the immune system to control the inflammatory process. Management of anterior scleritis involves collaborative care between an ophthalmologist and a rheumatologist, especially when a systemic association is present.