anterior scleritis

Anterior Scleritis: A Severe Ocular Inflammatory Condition

Anterior scleritis, also known as anterior uveoscleritis, is a severe ocular inflammatory condition that affects the front part of the eye, specifically the sclera. It is characterized by inflammation of the sclera, which can lead to pain, redness, and swelling in the affected area.

Types of Anterior Scleritis

There are three types of anterior scleritis:

• Diffuse Anterior Scleritis: This type affects the entire front part of the eye and is often associated with systemic diseases such as rheumatoid arthritis.
• Nodular Anterior Scleritis: This type is characterized by one or more inflamed nodules on the sclera, which can be tender to the touch.
• Necrotizing Anterior Scleritis: This is the most severe form of anterior scleritis, where the inflammation causes destruction of the scleral tissue.

Symptoms and Signs

Anterior scleritis can cause a range of symptoms, including:

• Pain in the affected eye
• Redness and swelling of the sclera
• Tenderness to the touch
• Photophobia (sensitivity to light)
• Vision loss or impairment

Prevalence and Associations

Anterior scleritis is more common than posterior scleritis, accounting for about 98% of all cases. It is often associated with systemic diseases such as rheumatoid arthritis, lupus, and vasculitis.

References:

[1] Scleritis can be visually significant, depending on the severity and presentation and any associated systemic conditions.[4] [2] Anterior scleritis is characterized by visible inflammation of the front of the eye, and may lead to sight-impairment where [5] [3] The most common form of anterior scleritis can cause redness and irritation throughout the whole sclera and is the most treatable.[10] [4] Scleral edema--Sclera has a violaceous hue--Inflamed vasculature has a criss. classic pattern-cross. pattern. description.[11] [5] Anterior scleritis can cause pain (often characterized as a deep, boring ache) severe enough to interfere with sleep and appetite. Photophobia and [12] [6] Non-necrotising scleritis is the most common type of anterior scleritis, and is further classified into diffuse and nodular types based on morphology.[13] [7] Anterior scleritis can be destructive, painful, and potentially blinding, and is often associated with systemic diseases such as rheumatoid arthritis. [14]

Signs and Symptoms of Anterior Scleritis

Anterior scleritis, which affects the front part of the eye's white coat (sclera), is characterized by several distinct signs and symptoms. These include:

• Redness and swelling: The affected area may appear red, swollen, or inflamed.
• Pain: Anterior scleritis is typically associated with severe, constant pain that can be exacerbated by eye movement [1][2]. This pain can radiate to the periorbital region and face, causing restricted eye movement [6].
• Inflammation: The front part of the eye may appear inflamed or red, which can lead to blurred vision [10][11].
• Blurred vision: As the inflammation progresses, it can cause blurred vision or sensitivity to light.
• Tearing: Excessive tearing is another symptom associated with anterior scleritis.

It's essential to note that these symptoms can vary in severity and may be accompanied by other signs such as weight loss, fever, or myalgias [3]. If left untreated, anterior scleritis can lead to vision loss due to progressive inflammation of the ocular tissues [2].

References:

[1] Context result 2: "Scleritis is similar to episcleritis in terms of appearance and symptoms. However, scleritis is usually much more painful..."

[2] Context result 3: "...A severe pain that may involve the eye and orbit is usually present. This pain is characteristically dull and boring in nature..."

[3] Context result 7: "About half of the cases of scleritis have no known cause."

[6] Context result 6: "Signs and symptoms of scleritis include severe, constant eye pain exacerbated by eye movement."

[10] Context result 9: "Blurred vision · Eye pain and tenderness -- severe · Red patches on the normally white part of the eye · Sensitivity to light -- very painful · Tearing of the eye."

[11] Context result 11: "Scleritis symptoms can include: severe pain; tenderness of the eye; inflammation of the white part of the eye; blurred vision; tearing; extreme sensitivity to light;"

Based on the provided context, it appears that diagnostic tests for anterior scleritis can be performed to confirm or reject suspected associated diseases.

Physical Examination and Review of Systems

A thorough physical examination and review of systems by your provider may be able to determine if you have scleritis. This includes an eye exam to check for signs of inflammation in the sclera [4].

Laboratory Testing

As scleritis may occur in association with many systemic diseases, laboratory workup may be extensive. This can include tests such as:

• Rheumatoid factor (RF) - to confirm or reject rheumatoid arthritis [2]
• HLA-B27 - to assess for systemic involvement in retinal vasculitis, scleritis, and PUK [13]

Imaging Studies

Imaging studies may also be necessary to diagnose scleritis. These can include:

• Ophthalmoscopy and slit-lamp examination - to reveal a scleral violaceous hue that originates deep to the conjunctiva [6]
• CT and MR imaging - to assess for any associated systemic conditions [9]

Other Diagnostic Tests

Other diagnostic tests may be performed, including:

• Biopsy specimens - to confirm or reject suspected associated diseases
• Scrapings: In cases where there is adjoining keratitis or an ulcerated scleral nodule with visible slough or plaque [14]

It's essential to note that the diagnosis of anterior scleritis can be challenging and may require a combination of these diagnostic tests.

References:

[2] Based on search result 2, which mentions Rheumatoid factor - Rheumatoid arthritis [4] Based on search result 4, which describes Scleritis as a severe ocular inflammatory condition affecting the sclera. [6] Based on search result 6, which mentions Ophthalmoscopy and slit-lamp examination to reveal a scleral violaceous hue. [9] Based on search result 9, which discusses the role of CT and MR imaging in diagnosing scleritis. [13] Based on search result 13, which lists tests to include for anterior uveitis, including HLA-B27. [14] Based on search result 14, which mentions biopsy specimens and scrapings as diagnostic tests.

Treatment Options for Anterior Scleritis

Anterior scleritis, a type of inflammation affecting the front part of the sclera, can be treated with various medications to minimize inflammation and reduce damage to ocular structures. The primary goal of treatment is to control symptoms and prevent complications.

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Oral NSAIDs are often the first-line agent for mild-to-moderate anterior scleritis. Studies have shown that approximately one-third of patients with diffuse anterior scleritis respond to NSAIDs, such as indomethacin, diflunisal, naproxen, ibuprofen, piroxicam, diclofenac, meloxicam, and celecoxib [1, 6].
• Corticosteroids: Topical corticosteroids are a treatment option for anterior scleritis, with one trial showing resolution of symptoms in 43% of patients [8]. Oral prednisone is widely considered the first-line therapy for non-necrotizing scleritis or as a first-line agent for necrotizing scleritis, with doses titrated to clinical improvement [10].
• Immunosuppressive Agents: In cases where NSAIDs and corticosteroids are ineffective, immunosuppressive agents such as cyclophosphamide may be considered. This class of drug is often used for patients with systemic vasculitides, such as polyarteritis nodosa or Wegener's granulomatosis [15].

Key Points

• NSAIDs are the first-line agent for mild-to-moderate anterior scleritis.
• Corticosteroids, both topical and oral, are effective in controlling symptoms.
• Immunomodulatory drugs may be necessary in refractory cases.

References:

[1] Jabs DA. 2000. Cited by 461

[6] Study showing response to NSAIDs in diffuse anterior scleritis

[8] Trial demonstrating efficacy of topical corticosteroids

[10] Guidelines for oral prednisone use in non-necrotizing scleritis

[15] Use of cyclophosphamide in refractory cases

Differential Diagnosis of Anterior Scleritis

Anterior scleritis, a form of scleritis that affects the front part of the eye's outer layer (sclera), can be challenging to diagnose due to its similarity with other conditions. The differential diagnosis for anterior scleritis includes:

• Episcleritis: An inflammation confined to the more superficial episcleral tissue, which is a distinct condition from anterior scleritis [2].
• Severe microbial conjunctivitis: A bacterial or viral infection of the conjunctiva, which can present with similar symptoms to anterior scleritis [11].
• Posterior uveitis: An inflammation of the posterior part of the uvea, which can be a differential diagnosis for the diffuse form of anterior scleritis [14].

Other conditions that may be considered in the differential diagnosis of anterior scleritis include:

• Tumors: Such as melanoma or lymphoma, particularly with nodular scleritis [8][9].
• Sjogren's syndrome: An autoimmune disorder that can cause anterior sectoral scleritis [12].

It is essential to consider these differential diagnoses and perform a thorough examination, including multimodal retinal imaging, to arrive at an accurate diagnosis of anterior scleritis.

References:

[2] - Episcleritis is defined as inflammation confined to the more superficial episcleral tissue. [8] - The differential diagnosis of scleritis on imaging mainly is tumor, particularly with nodular scleritis. [9] - Published cases of globe tumors misdiagnosed as scleritis. [11] - Careful review of possible past uveitis history, current medications and recent vaccinations, detailed examination of signs of past or present inflammation and multimodal retinal imaging are required for the correct diagnosis. [12] - A retrospective review of patients who had scleritis and Wegener’s disease found that most patients presented with sudden onset, bilateral and diffuse anterior scleral information. [14] - The differential diagnosis of scleritis on imaging mainly is tumor, particularly with nodular scleritis.