Rheumatic episcleritis and scleritis: causes, symptoms, diagnosis, treatment

Rheumatism and rheumatoid diseases occupy a prominent place among various causes of ocular pathology. Epiclerites and sclerites in rheumatism are more common than tephonites and myositis and affect mainly people of young and mature age, equally often men and women. One, more rarely both eyes. Among the etiological factors rheumatism and rheumatoid diseases take the first place, followed by gout, allergy, focal infection, tuberculosis.

[1], [2], [3], [4], [5]

Symptoms of rheumatic episcleritis and scleritis

In the clinical picture, there are no any etiological signs, which complicates the causal diagnosis. The development of scleral disease on the background of active rheumatism or post-streptococcal infection, cooling, in a patient with acquired valvular heart disease testifies to its rheumatic nature. If there is a suspicion of rheumatism, then clarification of the etiology requires the exclusion of other causes and antirheumatic therapy is trial. With rheumatic genesis, such treatment, as a rule, gives good results.

Clinical episcleritis and sclerites manifest usually fairly clear symptoms, which facilitates their nosological recognition.

Epicleritis is characterized by the development of non-inflammatory inflammatory infiltration of the episcleral tissue and the surface layers of the sclera in a limited area of the anterior surface of the eyeball, more often in the corneal limb. With this "nodular" process, the infiltrate in the form of a rounded formation rises above the sclera and the reddish-bluish color shines through the conjunctiva freely shifted over it. The latter over the node is hyperemic, and as a result of the expansion of the vessels, the affected area is even more prominent. At palpation, the pathological focus is painful, with pain spontaneous pain, as well as photophobia and lacrimation, are poorly expressed. Pain and eye irritation increase with complication of episcleritis with uveitis. Sometimes subconjunctival inflammatory nodes are two or more, and when they merge, a more common lesion occurs. Most often, the episcleral infiltrate occurs at the outer or inner limb in the area of the open ocular gap, and on the opposite side, too, a conjunctiva injection appears on the limb in a limited area, which further emphasizes the unhealthy appearance of the eye.

The disease develops gradually, proceeds slowly and after a few weeks it ends with resorption of the infiltrate without a trace or with the leaving of an unobtrusive hem under the conjunctiva. Often one eye is affected, and if both eyes fall ill, it is not always simultaneous. There are frequent relapses, especially rheumatic episcleritis.

The heavier lesion of the eyes is sclerites: anterior knot ankular, hyperplastic, posterior malignant, etc. Rheumatism has two more first forms.

Nodular scleritis in the clinic is similar to a nodular crypt. But differs from it by deeper infiltration of the sclera in the affected area (areas) and greater severity of all the symptoms of the disease. Scleral infiltrates with this suffering differ dark red with a violet hue of color, reach the size of a half of a large pea, often multiple, and with an ankular form a ring surrounds the cornea. Histologically, necrosis, melokokistoznuyu moonuclear, lymphocytic, less often leukocyte infiltration, as well as Ashot-talalayevsky granulomas, are detected histologically in the scleral thickness and along the anterior ciliary vessels. The course of the disease greatly aggravates the inflammation of the anterior part of the vascular tract joining almost to all sclerites, where the process spreads from the sclera to the ciliary vessels. The imbrication of serous-plastic or plastic uveitis entails corresponding subjective and objective symptoms: pain, photophobia, lacrimation, pericorneal injection, precipitates, posterior synechia, vitreous suspension, etc.

With a significant degree of uveitis, these symptoms mask scleritis and make it difficult to diagnose as a primary primary disease. In connection with this, with uveitis, it is impossible to ignore the unusual color of individual sections of the surface of the eyeball, the swelling of these areas, similar to the nodes of formation, their painfulness upon palpation, unusual for pericorneal or mixed injections, etc. Having diagnosed scleritis, one can explain the occurrence of vascular disease and clarify its etiology.

In addition to the described forms of scleral disease, rheumatism can manifest as diffuse granulomatous sclerites, and in the form of perforating scleromalia. The latter is manifested by the appearance on some part of the anterior eyeball of softening of the sclera of dark color. Irritation and eye pain can be expressed in varying degrees. Despite the most vigorous measures, up to scleroplasty, the softening, having captured a fairly large zone, is steadily spreading into the depths and after a while perforates the wall of the eye. The disease ends with a hundred atrophy.

Along with the anterior section, rheumatoid sclerites can affect the posterior pole of the eyeball. Well-known, for example, malignant scleritis. Developing near the optic nerve disc, it often mimics the intraocular swelling and is only recognized histologically after enucleation of the eye. Despite the diagnostic error, the removal of the eyeball in such patients is justified, since the disease is incurable and fraught with serious consequences. However, this sclerite is observed very rarely.

Much greater practical interest may be the sluggish and imperceptibly flowing back rheumatic sclerites. Causing, however, weakening of the sclera and its stretching with the progression of myopia, especially in those suffering from rheumatism and children.

All forms of sclerites in patients with rheumatism are considered as a single disease with differences only in the depth of lesion, localization, extent along the surface of the eye, the severity of subjective and other symptoms. They are considered a manifestation of the true rheumatic process in the vascular rich and mesenchymal episclera, as well as in the scleral tissue, and therefore all these diseases are united in a single concept of "rheumatoid scleritis". Leading importance in its development is given to allergotypergic reactions such as infectious allergies. Successful therapy, mainly glucocorticoids, in most patients with rheumatoid scleritis confirms the validity of this view.

Treatment of rheumatic episcleritis and sclerites

In the treatment of episcleritis and sclerites with glucocorticoids, other antiallergic and symptomatic therapies recommended above may be useful.

The abscess of the sclera occurs metastatically in the presence of a purulent foci in the body. The disease begins suddenly on the background of pain and manifests itself in the form of hyperemia and limited swelling, usually near the limbus, which quickly turns into a purulent nodule with further softening and opening.

Recommendations:

• consultation and treatment with an ophthalmologist;
• frequent instillation of broad-spectrum antibiotics and iodinol;
• instillation of mydriatic (scopolamine 0.25%, atropine 1%);
• antibiotics of a wide spectrum of action inside, intramuscularly or intravenously;
• treatment of the underlying disease.