Medical expert of the article
New publications
Rheumatic episcleritis and scleritis: causes, symptoms, diagnosis, treatment
Last reviewed: 07.07.2025

All iLive content is medically reviewed or fact checked to ensure as much factual accuracy as possible.
We have strict sourcing guidelines and only link to reputable media sites, academic research institutions and, whenever possible, medically peer reviewed studies. Note that the numbers in parentheses ([1], [2], etc.) are clickable links to these studies.
If you feel that any of our content is inaccurate, out-of-date, or otherwise questionable, please select it and press Ctrl + Enter.
Rheumatism and rheumatoid diseases occupy a prominent place among the various causes of eye pathology. Episcleritis and scleritis in rheumatism are more common than teponitis and myositis and affect mainly young and mature people, equally often men and women. One eye, less often both, is affected. Among the etiologic factors, rheumatism and rheumatoid diseases occupy the first place, followed by gout, allergy, focal infection, tuberculosis.
Symptoms of rheumatic episcleritis and scleritis
The clinical picture lacks any etiological signs, which complicates causal diagnosis. The development of scleral disease against the background of active rheumatism or post-streptococcal infection, cooling, in a patient with acquired valvular heart disease indicates its rheumatic nature. If rheumatism is suspected, other causes must be excluded and antirheumatic therapy must be trialed to clarify the etiology. In case of rheumatic genesis, such treatment usually gives good results.
Clinical episcleritis and scleritis usually manifest themselves with fairly clear symptoms, which facilitates their nosological recognition.
Episcleritis is characterized by the development of non-purulent inflammatory infiltration of the episcleral tissue and superficial layers of the sclera in a limited area of the anterior surface of the eyeball, most often at the corneal limbus. In such a "nodular" process, the infiltrate in the form of a rounded formation rises above the sclera and shines through the conjunctiva, which moves freely above it, in a reddish-bluish color. The latter is hyperemic above the node, and due to the expansion of its vessels, the affected area stands out even more. On palpation, the pathological focus is painful, although spontaneous pain, as well as photophobia and lacrimation, are weakly expressed. Pain and irritation of the eye increase when episcleritis is complicated by uveitis. Sometimes there are two or more subconjunctival inflammatory nodes, and when they merge, a more widespread lesion occurs. Most often, episcleral infiltrate occurs at the outer or inner limbus in the area of the open eye slit, and on the opposite side, also at the limbus, a conjunctival injection appears in a limited area, which further emphasizes the unhealthy appearance of the eye.
The disease develops gradually, proceeds slowly and after a few weeks ends with the infiltrate resolving without a trace or leaving a barely noticeable scar under the conjunctiva. Most often one eye is affected, and if both eyes are affected, then not always at the same time. Relapses are not uncommon, especially of rheumatic episcleritis.
More severe eye damage is scleritis: anterior nodular ancular, hyperplastic, posterior malignant, etc. Rheumatism is more characterized by the first two forms.
Nodular scleritis is similar to nodular episcleritis in its clinical features, but differs from it in deeper scleral infiltration in the affected area (areas) and greater severity of all symptoms of the disease. Scleral infiltrates in this disease are dark red with a violet tint, reach the size of half a large pea, are often multiple, and in the ancular form surround the cornea with a ring. Histologically, necrosis, small cystic myonuclear, lymphocytic, less often leukocytic infiltration, as well as Aschoff-Talalaev granulomas are found in the thickness of the sclera and along the anterior ciliary vessels. The course of the disease is greatly aggravated by inflammation of the anterior vascular tract, which joins almost all scleritis, where the process spreads from the sclera along the ciliary vessels. The superposition of serous-plastic or plastic uveitis entails corresponding subjective and objective symptoms: pain, photophobia, lacrimation, pericorneal injection, precipitates, posterior synechiae, suspension in the vitreous body, etc.
With significant expression of uveitis, the above symptoms mask scleritis and complicate its diagnosis as the main primary disease. In this regard, in case of uveitis, one cannot ignore the unusual color of individual areas of the eyeball surface for a pericorneal or mixed injection, swelling of these areas, formations similar to nodes, their soreness upon palpation, etc. Having diagnosed scleritis, one can explain the occurrence of the vascular tract disease and clarify its etiology.
In addition to the described forms of scleral disease, rheumatism may manifest itself as diffuse granulomatous scleritis, as well as in the form of perforating scleromalacia. The latter is manifested by the appearance of a dark-colored softening of the sclera in some area of the anterior eyeball. Irritation and pain in the eye may be expressed to varying degrees. Despite the most energetic measures, including scleroplasty, the softening, having captured a fairly large area, steadily spreads into the depths and after some time perforates the wall of the eye. The disease ends with atrophy.
Along with the anterior section, rheumatoid scleritis can affect the posterior pole of the eyeball. For example, malignant scleritis is well known. Developing near the optic nerve head, it often imitates intraocular swelling and is recognized only histologically after enucleation of the eye. Despite the diagnostic error, removal of the eyeball in such patients is justified, since the disease is incurable and fraught with severe consequences. However, such scleritis is observed very rarely.
Of much greater practical interest may be the sluggish and unnoticeable posterior rheumatic scleritis, which, however, causes weakening of the sclera and its stretching with the progression of myopia, especially in those suffering from rheumatism and children.
All forms of scleritis in patients with rheumatism are considered as a single disease with differences only in the depth of the lesion, localization, extent on the surface of the eye, severity of subjective and other symptoms. They are considered a manifestation of a true rheumatic process in the episclera, which is rich in vessels and mesenchyme, as well as in the tissue of the sclera, and therefore all these diseases are combined into a single concept of "rheumatoid scleritis". The leading role in its development is given to allergic hyperperergic reactions of the infectious allergy type. Successful therapy, mainly with glucocorticoids, in most patients with rheumatoid scleritis confirms the validity of this view.
What do need to examine?
How to examine?
Treatment of rheumatic episcleritis and scleritis
In the treatment of episcleritis and scleritis with glucocorticoids, other antiallergic and symptomatic therapy recommended above may be useful.
An abscess of the sclera occurs metastatically in the presence of a purulent focus in the body. The disease begins suddenly against the background of pain and manifests itself in the form of hyperemia and limited swelling usually near the limbus, quickly turning into a purulent nodule with its subsequent softening and opening.
Recommendations:
- consultation and treatment with an ophthalmologist;
- frequent instillation of broad-spectrum antibiotics and iodinol;
- instillation of mydriatics (0.25% scopolamine, 1% atropine);
- broad-spectrum antibiotics orally, intramuscularly or intravenously;
- treatment of the underlying disease.