Approach Considerations
A primary complaint of atraumatic eye pain rarely necessitates prehospital care, other than expedient transport to the emergency department (ED). Take care not to overlook serious comorbidity. If global perforation is suspected, shield the eye and avoid palpation.
It is important to differentiate infectious scleritis from noninfectious scleritis, because corticosteroids or immunosuppressive agents are contraindicated in active infection. Patients with infectious scleritis should be treated with appropriate and specific antimicrobial therapy. [22, 28]
Recognition of the problem and timely ophthalmology referral are cornerstones of ED management. Severity of scleritis and depth of involvement determine the urgency of ophthalmology consultation. [5] Serious systemic illness and initiation of immunosuppressive therapy may require coordination with an internist and/or rheumatologist.
Emergency Department Care
Therapeutic goals for scleritis are to relieve the patient’s pain and initiate therapy that will positively alter the course of the disease. [31] From the patient's perspective, pain cessation may be the most important action taken by the emergency practitioner. Outcome in cases of noninfectious scleritis will depend on the patient's response to immunosuppressive therapy. [32]
Narcotics and systemic nonsteroidal anti-inflammatory drugs (NSAIDs) may render temporary pain relief and can be started in the ED. A variety of NSAIDs is available to choose from, including diflunisal, naproxen, indomethacin, piroxicam, sulindac, and ibuprofen. These are particularly effective in nodular and diffuse scleritis and ordinarily are prescribed for at least 1 week.
Detection of scleral thinning mandates application of an eye shield to the involved eye to decrease risk of perforation. Ensure that the eye guard does not contact the eyelid or globe. Apply tape from the forehead to zygoma. If an eye shield is not available, use a paper or polystyrene cup, provided it is large enough to cover the eye without placing undue pressure on the globe.
Scleritis treatment will require immunomodulator therapy once the definitive diagnosis is made. High-dose oral prednisone is used primarily in necrotizing scleritis and severe nonnecrotizing scleritis. Immunosuppressives are used as an adjunct when steroids alone fail to control progression of the disease and include cyclosporine, azathioprine, cyclophosphamide, and methotrexate. Increasing evidence supports a role for rituximab in refractory disease. [15] These drugs have serious side effects and contraindications and should be prescribed only by a physician who is well aware of their actions.
The emergency practitioner can discuss using a topical steroid agent with the ophthalmologist. [33] Although topical steroid therapy typically fails, it could be considered as first-line treatment for nonnecrotizing anterior scleritis, especially in cases in which the likelihood of complications from systemic steroid or NSAID therapy is high. [33]
Inpatient care rarely is indicated for scleritis, unless complicated by serious exacerbation of underlying disorder. Surgical management is generally not required except in rare cases of necrotizing scleritis.
