Scleritis: Symptoms, Causes and Treatment

Scleritis is painful swelling and redness of the sclera, the tough white outer wall of the eye. It causes a deep, boring eye pain and a dark red or purplish color, and it can damage vision if it isn’t treated. About half of people with scleritis have an immune system disease elsewhere in the body, such as rheumatoid arthritis, so it needs prompt care from an eye doctor and often a full medical workup.

Key points

Scleritis pain is severe, often spreads to the brow, jaw or temple, and can wake you at night.
It is a different problem from pink eye (conjunctivitis) and from episcleritis, a milder redness of the eye’s surface layer.
It is often linked to rheumatoid arthritis, vasculitis or other autoimmune diseases. Infections cause a smaller share of cases.
Treatment usually needs medicine by mouth or by infusion. Eye drops alone are rarely enough.
See an eye doctor the same day for a red, painful eye with blurred vision.

What causes scleritis

In most cases, the immune system attacks the sclera by mistake. Conditions linked to scleritis include:

Rheumatoid arthritis, the most common one
Granulomatosis with polyangiitis (Wegener’s) and other forms of vasculitis (inflamed blood vessels)
Lupus, relapsing polychondritis, inflammatory bowel disease and spondyloarthritis

Less often, scleritis comes from an infection, such as shingles near the eye, syphilis or tuberculosis, or from germs entering after eye surgery or an injury. A few medicines, including bisphosphonates for osteoporosis, can trigger eye inflammation, including scleritis. Sometimes no cause is found. Scleritis is most common in women between 40 and 60.

Types of scleritis

Anterior scleritis affects the front, visible part of the eye. It can be spread out over a wide area (diffuse), form a tender raised bump (nodular), or destroy tissue (necrotizing). Necrotizing scleritis is the most serious type and can thin the eye wall.
Posterior scleritis affects the back of the eye. The eye may look only a little red, but pain, blurred vision and pain when moving the eye are common.

Scleritis symptoms

Deep, aching eye pain that may spread to the forehead, temple, jaw or face
Pain that is worse at night or early morning and when you move the eye
Redness that looks deep red, violet or bluish rather than pink
A tender eye when touched through the eyelid
Tearing and sensitivity to light
Blurred or reduced vision

Scleritis usually doesn’t cause the sticky discharge of pink eye. It affects one eye or both, sometimes taking turns.

How scleritis is diagnosed

An eye doctor (ophthalmologist) looks closely at the eye with a slit lamp, a microscope with a bright light. They may put in a drop of phenylephrine, which shrinks the surface blood vessels. In episcleritis, the redness fades. In scleritis, the deep vessels stay red. The doctor also widens your pupils to check the inside of the eye. An ultrasound of the eye helps find posterior scleritis.

Because scleritis is so often tied to disease elsewhere in the body, you may also have:

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Blood tests for rheumatoid arthritis, lupus and vasculitis (such as ANCA), plus markers of inflammation
Tests for syphilis and tuberculosis
A urine test and kidney blood tests, since vasculitis can affect the kidneys
A chest X-ray or CT scan

A rheumatologist often joins your care. Sometimes scleritis is the first sign of a serious illness, and finding it early protects other organs too.

How scleritis is treated

NSAIDs. For milder cases that aren’t necrotizing, anti-inflammatory pills such as naproxen or indomethacin may control the swelling and pain.
Steroids. Prednisone or a similar steroid by mouth is used when NSAIDs aren’t enough. Very severe cases may start with steroids through a vein. Steroid eye drops can ease symptoms but rarely control scleritis on their own.
Immune-suppressing medicines. Methotrexate, mycophenolate or azathioprine let the doctor lower steroid doses and keep scleritis from returning.
Biologic drugs. Rituximab, or TNF blockers such as infliximab and adalimumab, are used for severe or stubborn scleritis and for scleritis linked to vasculitis or rheumatoid arthritis.
Treating infection. If a germ is the cause, antiviral, antibiotic or antifungal medicine is needed instead of strong immune suppression.
Surgery. If the sclera has become very thin or has a hole, a patch of donor tissue can repair it.

Many of these medicines raise the risk of infection and need regular blood tests. Your doctors will watch for side effects as well as for signs that the scleritis is calming down.

Recovery and outlook

With treatment, the pain usually improves within days to weeks. Scleritis can last months and may come back, so some people take medicine for a long time. Possible complications include thinning of the sclera, inflammation inside the eye (uveitis), glaucoma, cataract, swelling of the retina and vision loss. Prompt treatment and steady follow-up lower these risks.

When to see a doctor

See an eye doctor the same day, or go to an emergency department, if you have:

A red eye with moderate or severe pain
Eye pain that wakes you up
Blurred vision or new sensitivity to light
Eye redness or pain and you have rheumatoid arthritis or another autoimmune disease

If you are being treated for scleritis, call your doctor about worsening pain, vision changes, fever or other signs of infection.

Common questions about scleritis

What is the difference between scleritis and episcleritis?

Episcleritis affects only the thin layer on top of the sclera. It causes mild irritation and pink or bright red patches, often clears in 1 to 3 weeks, and rarely harms vision. Scleritis goes deeper, hurts much more, looks darker red and can threaten sight.

Is scleritis contagious?

No. Most scleritis comes from the immune system, not from a germ, so you can’t pass it to others. Even when an infection such as shingles is the cause, scleritis doesn’t spread like pink eye. You can go to work or school when you feel well enough.

Can scleritis cause blindness?

It can, especially necrotizing scleritis and posterior scleritis. Thinning of the eye wall, glaucoma, cataract and retinal swelling can all lead to vision loss. Starting treatment early and following up closely with an eye doctor greatly lowers the chance of lasting damage.