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Review Sclera Scleritis—Infectious Versus Inflammatory Felipe A Valenzuela and Victor L Perez Ocular Surface Center, Bascom Palmer Eye Institute, University of Miami, Florida, US S cleritis refers to a heterogeneous group of diseases characterized by a severe painful inflammatory process of the sclera, that may also involve the cornea, adjacent episclera, and underlying uveal tract. It is associated with significant ophthalmic and systemic morbidity. Scleritis sometimes occurs in an isolated fashion, without evidence of inflammation in other organs. However, in up to 50% of patients, scleritis is associated with an underlying systemic illness such as rheumatoid arthritis or granulomatosis with polyangiitis. Infection is an important but rare cause of scleritis, occurring in about 5–10% of all cases. Due to the similarity of its presentation, infectious scleritis is often initially managed as autoimmune, potentially worsening its outcome. Careful clinical history taking (including history of ocular surgery), detailed ocular examination, appropriate investigation for ocular disease with or without underlying systemic disease, and timely intervention has improved the long-term outcome for patients with this disease. Keywords Scleritis, infectious, autoimmune, vasculitides, pterygium, immunomodulatory therapy Disclosure: Felipe A Valenzuela and Victor L Perez have nothing to disclose in relation to this article. No funding was received in the publication of this article. This study involves a review of the literature and did not involve any studies with human or animal subjects. performed by any of the authors. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: July 4, 2016 Accepted: August 26, 2016 Citation: US Ophthalmic Review, 2016;9(2):92–6 Corresponding Author: Victor L Perez, University of Miami Miller School of Medicine (UM), William McKnight Research Building, 1638 NW 10th Avenue, #613 Miami – Florida 33136, US. E: firstname.lastname@example.org Scleritis refers to a heterogeneous group of diseases characterized by inflammation of the sclera, which may also involve the cornea, adjacent episclera, and underlying uveal tract. 1 In contrast to episcleritis, scleritis is associated with significant ophthalmic and systemic morbidity. 2 Patients who are not appropriately diagnosed and treated are at high risk of vision loss owing to the progressive destruction of the eye and other associated ophthalmic complications. Moreover, the presence of scleritis can be the initial manifestation of a potentially lethal systemic vasculitis or can be the sole sign of active systemic disease of an already diagnosed inflammatory disorder. 3 Therefore, the recognition and prompt treatment of scleritis could not only protect the eye, but also prolong the life of the patient. Specific etiologies of scleritis, varying from idiopathic to autoimmune to infectious, portend variable disease severity and outcome. Scleritis sometimes occurs in an isolated fashion, without evidence of inflammation in other organs. However, in up to 50% of patients, scleritis is associated with an underlying systemic illness such as rheumatoid arthritis (RA) or granulomatosis with polyangiitis (Wegener’s). 1 Infection is an important but rare cause of the scleritis, occurring in about 5–10% of all cases. 4 Geographical location should be considered, as infectious scleritis is more commonly seen in the southern area of the United States. 5 However, owing to the similarity of its presentation, infectious scleritis is often initially managed as autoimmune, potentially worsening its outcome. Clinical features Scleritis can occur in any age group, but most commonly presents between the fourth and sixth decades of life; women are affected approximately twice as often as men. 6,7 The primary clinical sign of scleritis is redness associated with severe pain. The redness has a bluish red appearance, tends to progress with time and can be sectorial or involve the whole eye. The pain is described as dull, aching, or boring and it may be severe and constant; it often awakens patients from sleep and is poorly responsive to analgesics. Patients complain of deep pain that radiates from the eye to the forehead, orbit and even the sinuses in some instances. It is exacerbated by touching the eye or by pressing the periocular area. Other complaints may include tearing, photophobia, and decreased vision (especially in posterior scleritis). 2,7 Slit lamp examination shows edema of the episcleral and scleral tissue, with congestion of the deep episcleral plexus. The use of topical vasoconstrictors has minimal effect on these vessels and in contrast to episcleritis, the redness of scleritis will not be resolved with the instillation of 10% phenylephrine or 1:1000 epinephrine. 92 TOUCH ME D ICA L ME D IA