Sclerite

Scleritis is a severe destructive, eye-threatening inflammation involving the deep layers of episclera and sclera. Scleral infiltration is similar to episcleral. Often, one, sometimes two or more uchaskov inflammation at the same time. In severe cases, it can cover the entire pericorneal area. Usually, inflammation develops against the background of a general immune pathology in middle-aged women. In half of the cases, the scleritis is bilateral.

Symptoms are manifested in moderate pain, hyperemia of the eyeball, lacrimation and photophobia. The diagnosis is established clinically. Treatment is carried out by systemic glucocorticoids, it is possible to use immunosuppressors.

[1], [2], [3], [4], [5], [6]

Causes of the sclerite

Scleritis is most common in women aged 30-50 years, and many have connective tissue diseases, such as rheumatoid arthritis, SLE, periarteritis nodosa, Wegener's granulomatosis, or recurrent polychondritis. Some cases are caused by infection. Sclerites most often involve the anterior segment and are of 3 types: diffuse, nodular and necrotizing (perforating scleromalacia).

The causes of sclerite are very diverse. Previously, the most common causes of scleritis were tuberculosis, sarcoidosis, and syphilis. Currently, streptococcal infection, pneumococcal pneumonia, inflammation of the paranasal sinuses, any inflammatory focus, metabolic diseases - gout, and collagenosis play a leading role in the development of scleritis. Some authors point to the relationship of scleritis due to rheumatism and polyarthritis. Pathological processes in scleritis develop according to the type of bacterial allergy, sometimes they have an autoimmune character, which causes their persistent recurrent course. Injuries (chemical, mechanical) can also cause sclera diseases. With endophthalmitis, panophthalmitis, there may be a secondary lesion of the sclera.

Thus, the following sclerite causes

• In almost 50% of cases, the development of scleritis occurs against the background of systemic diseases of the body. The most common diseases are rheumatoid arthritis, Wegener granulomatosis, recurrent polychondritis and nodular polyarthritis.
• Post-surgical scleritis. The exact cause is unknown, but there is a clear relationship with existing systemic diseases; most common in women. The appearance of scleritis is typical within 6 months after surgery in the form of a site of intense inflammation and necrosis, which is adjacent to the area of operation.
• Infectious scleritis is most often caused by the spread of an infectious process from a corneal ulcer.

Scleritis can also be associated with traumatic injury, removal of pterygium, the use of beta radiation or mitomycin C. The most frequent infectious agents are Pseudomonas aeruginosa, Strept. Pneumoniae, Staph. Aureus and herpes zoster virus. Pseudomonas scleritis is difficult to treat, and the prognosis of such scleritis is unfavorable. Fungal scleritis is rare

[7], [8]

Symptoms of the sclerite

Scleritis begins gradually, over several days. Scleritis is accompanied by severe pain. The pain may radiate to other parts of the head. The eyeball is sore. The pain (often described as deep, boring pain) is strong enough to interrupt sleep and disturb appetite. Photophobia and lacrimation may occur. The affected areas have a red color with a violet hue, often surrounding the entire cornea ("annular sclerite"). Very often scleritis is complicated by corneal diseases (sclerosing keratitis and inflammatory process in the iris and ciliary body). Involvement of the iris and ciliary body is expressed in the formation of adhesions between the pupillary edge of the iris and the crystalline lens, the turbidity of the anterior chamber and deposition of precipitates on the posterior surface of the cornea. The conjunctiva is soldered to the affected area of the sclera, the vessels intersect in different directions. Sometimes scleral edema is detected.

Hyperemia spots occur deep under the conjunctiva of the eyeball and are distinguished by a violet tinge from hyperemia with episcleritis. Conjunctiva is normal. The area involved may be local (i.e., one quadrant of the eyeball) or involve the entire eyeball and may contain a hyperemic, edematous raised nodule (nodular scleritis) or avascular zone (necrotizing scleritis).

In severe cases of necrotizing scleritis, perforation of the eyeball may occur. Connective tissue diseases are found in 20% of patients with diffuse or nodular sclerite and in 50% of patients with necrotizing scleritis. Necrotizing scleritis in patients with connective tissue disease signals the underlying systemic vasculitis.

Necrotizing scleritis - most often occurs with inflammation, less often - without an inflammatory reaction (perforating scleromalacia).

Necrotizing scleritis without inflammatory reaction often occurs on the background of long-existing rheumatoid arthritis, proceeds without serious consequences. The sclera gradually becomes thinner, it mines outwards. At the slightest injury easily comes scleral rupture.

Posterior scleritis is rarely observed. Patients complain of pain in the eye. They find eye tension, sometimes limiting its mobility, may develop exudative retinal detachment, swelling of the optic nerve head. When carrying out an echography and a tomography it is possible to reveal thinning of a sclera in a back section of an eye. Rear scleritis usually begins with common diseases of the body (rheumatism, tuberculosis, syphilis, herpes zoster) and is complicated by keratitis, cataracts, iridocyclitis, increased intraocular pressure.

Deep scleritis occurs chronically, has a recurrent nature. In mild cases, resorption of infiltrate occurs without serious complications.

With massive infiltration in the affected areas, necrosis of the scleral tissue occurs and its scar replacement with subsequent thinning of the sclera. In places where there were areas of inflammation, there are always traces in the form of grayish areas as a result of thinning of the sclera, through which the pigment of the choroid and ciliary body shines through. As a result, stretching and protrusion of these sclera zones (scleral staphyloma) are sometimes observed. Vision is impaired by developing as a result of protrusion of the sclera, astigmatism, and the attendant changes that occur in the cornea and iris.

[9]

Forms

Scleritis is classified by anatomical criteria - anterior and posterior.

Among the anterior sclerites, the following clinical forms are distinguished: diffuse, nodular, and most rare - necrotizing.

[10],

Diagnostics of the sclerite

The diagnosis is established clinically and with a slit lamp. Samples or biopsies are necessary to confirm the infectious sclerite. CT scan or ultrasound may be necessary to diagnose the posterior sclerite.

[11], [12], [13], [14], [15]

Treatment of the sclerite

Primary therapy is systemic glucocorticoids (for example, prednisone 1 mg / kg 1 time per day). If the scleritis is tolerant to systemic glucocorticoids or the patient has necrotizing vasculitis and connective tissue disease, systemic immunosuppressive therapy with cyclophosphamide or azathioprine is indicated after consultation with a rheumatologist. If perforation is threatened, transplantation of scleral tissue may be indicated.

In the treatment of topically used corticosteroids (dexanos drops, masideks, ofan-dexametaeone or hydrocortisone-POS ointment), nonsteroidal anti-inflammatory drugs and the form of drops (naklof), cyclosporine (cycolin). Non-steroidal anti-inflammatory drugs (indomethacin, diclofenac) are also taken orally.

In necrotizing scleritis, which is regarded as an ocular manifestation of systemic diseases, immunosuppressive therapy (corticosteroids, cyclosporine, cytophosphamide) is necessary.

Forecast

14% of patients with scleritis significantly lose their visual acuity within 1 year, 30% - within 3 years. Patients with necrotizing scleritis and the underlying systemic vasculitis have a mortality rate of up to 50% within 10 years (mainly from a heart attack).

[16], [17], [18]