Scleritis,is considered a chronic inflammatory response that involves the superficial and deep episcleral plexus. The exact mechanism of inflammation in scleritis remains unclear, as some report a variety of immunopathological findings, while others point to granulomatous inflammation and collagen disruption, which can lead to loss of tissue and subsequent thinning. Scleritis has a proposed incidence of 4.1 cases per 100,000 person-years and can be idiopathic, associated with a systemic autoimmune disease, surgically induced or infectious, although only 4% to 10% of all cases are deemed infectious.Potential pathogens include bacteria, fungi, parasites and viruses.

1. A CASE REPORT ON SCLERITIS
Manish Dahal
Vasan Institute of Ophthalmology & Research
Bangalore-India

2.  A 66-year-old Indian male presented with bilateral red and mildly
painful eyes. He said his eyes had been getting red on and off, but this
episode was much worse.
PATIENT HISTORY:
 Done cataract surgery (OU) since 5 years
 Positive family ocular history

3.  Systemic disease like chronic respiratory issues with a persistent cough
for the past four to six months.
 Diagnosed with recurring bronchitis and was treated with several
courses of antibiotics as well as oral steroids.
 He had also lost an unexplained 20 lbs.
 Reporting generalized muscular pain.
 He was under medication at the time of visit. Durezol [difluprednate
0.05% QID]

4. VISUAL ACUITY
OD:20/25
OS:20/30
IOP
OD:18mmHg
OS:19mmHg
EOM: FULL OU;NO NYSTAGMUS
SLIT LAMP
showed bilateral sectoral nodular scleritis
[mostly superficial and some deeper episcleral
inflammation noted]
fig;Sectoral nodular scleritis

5. Management:
Lotepred e/d BE 4/3/2/1× 7 days
Milflox e/d BE 4t/d

6.  Considering his bilateral scleral inflammation along with his systemic
issues, additional lab testing was ordered, which included: RF, ANA,
HLAB27, Lyme, PPD, FTA-ABS, ACE, C-ANCA, P-ANCA, ESR, CRP.

7.  When he returned one week later, his eyes were white and quiet. His lab
results was reviewed, which showed significantly elevated ANCA and
CRP levels. His pulmonologist was contacted due to a high concern for
granulomatosis with polyangiitis (GPA, aka Wegener’s granulomatosis);
imaging studies and a lung tissue biopsy later confirmed the diagnosis. The
patient was sent to a GPA specialist for further evaluation and treatment.

8.  Half of all scleritis cases have an underlying systemic cause. So, a thorough history and
review of systems are very important to help identify any underlying etiologies and guide
laboratory studies or further medical evaluation.
GPA is often overlooked due to its rare incidence—just three cases per 100,000
people.Approximately 10% of patients with GPA develop scleritis, so ANCA testing should
be included in the workup of these patients.
 In addition to GPA, rheumatoid arthritis, relapsing polychondritis, polyarteritis nodosa,
systemic lupus erythematosus, sarcoidosis, anklyosing spondylitis herpes zoster, syphilis and
tuberculosis are associated with scleritis and should be tested as causative factors.
 The patient returned for follow-up six months later. He was tapering prednisone and had
started methotrexate for the GPA. The overall improvement in his health was remarkable. He
had gained back 20 lbs., and was feeling significantly better with no more breathing or
coughing issues. His scleral inflammation has been quiet since.

9. ommon Laboratory Tests for Patients with Scleritis
Laboratory Test Systemic Condition
ACE (angiotensin-converting
enzyme)
Chest X-ray
Sarcoidosis
ANA (antinuclear antibody) Lupus
c-ANCA (cytoplasmic
antineutrophil cytoplasmic
antibody)
Wegener's granulomatosis
p-ANCA (perinuclear
antineutrophil cytoplasmic
antiybody)
Vasculitis, polyarteritis nodosa
FTA-ABS (fluorescent
treponemal antibody
absorption)
RPR/VDRL (rapid plasma
reagin/venereal disease
reference laboratory)
Syphilis
ELISA (enzyme-linked
immunosorbent assay)
Western blot
Lyme disease
RF (Rheumatoid factor) Rheumatoid arthritis
CRP (C-reactive protein)
ESR (erythrocyte
sedimentation rate)
Nonspecific systemic
inflammation
Common Laboratory Tests for Patients with Scleritis
Laboratory Test Systemic Condition
ACE (angiotensin-converting enzyme)
Chest X-ray
Sarcoidosis
ANA (antinuclear antibody) Lupus
c-ANCA (cytoplasmic antineutrophil
cytoplasmic antibody)
Wegener's granulomatosis
p-ANCA (perinuclear antineutrophil cytoplasmic
antiybody) Vasculitis, polyarteritis nodosa
FTA-ABS (fluorescent treponemal antibody
absorption)
RPR/VDRL (rapid plasma reagin/venereal
disease reference laboratory)
Syphilis
ELISA (enzyme-linked immunosorbent assay)
Western blot
Lyme disease
RF (Rheumatoid factor) Rheumatoid arthritis
CRP (C-reactive protein)
ESR (erythrocyte sedimentation rate)
Nonspecific systemic inflammation