How to Diagnose and Manage Scleritis

    • CE credits 2 hours
    • COPE code 60406-AS / 116921
    • Available until Jan 2, 2022


Learning Objectives

  • To review the pathophysiology, classification, and features of scleritis
  • To review systemic disease associations of scleritis
  • To review the diagnosis and management of scleritis


A 58-year-old male presents to the eye clinic with a three-week history of a painful left eye. He says that his left eye has been constantly red the last few weeks, and he had an increasingly “dull” pain in and around the eye. He feels it is worse at night and has had difficulty sleeping, though, even during the day the pain is extremely bothersome. He notes significant impairments in his work performance and has become increasingly reclusive because of the pain. He has taken acetaminophen with little relief.

The patient notes no decreased vision or other visual symptoms from the eye. The pain occasionally feels as though it’s “behind the eye,” but he has otherwise had no headache. He has had no other general symptoms, such as fever or cold symptoms. Past medical history is significant only for chronic lower back pain and stiffness he has had since a teenager, but for which he has never seen a doctor. He is on no regular medications.

The exam visual acuity is 6/6 and 6/7.5 in the right and left eyes, respectively. Pressures are 12 in the right eye and 16 in the left eye. Anterior segment exam is remarkable for the external redness shown below. The involved vessels are non-mobile when a cotton-tip applicator is applied. Fundoscopy is difficult secondary to photophobia but appears to be normal.

Quick Question

What is the most likely diagnosis?

  • Iritis

    Although iritis may produce a red painful eye with photophobia (and this patient may indeed have an element of iritis), the underlying cause of the patient’s symptoms is not a primary iritis.

  • Episcleritis

    Episcleritis can cause a red eye, although severe pain is uncommon, and one would expect to find involved vessels movable with a cotton-tip applicator.

  • Scleritis
  • Conjunctivitis

    Conjunctivitis can cause a red eye, although the clinical picture (e.g., severe pain, involvement of deeper vessels) suggests an alternative diagnosis.


Scleritis is an important cause of a painful red eye. It is often associated with systemic abnormalities, and commonly affects middle-aged Caucasian patients with a mean age at onset of 49 years.1 It is more common in females than males (approximately 2:1).1 2

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