Scleritis and episcleritis

Abstract

The data from 159 patients (217 eyes) with episscleritis and 207 patients (301 eyes) with scleritis have been investigated in detail and the results analysed with the help of a computer. Of these patients, 91 per cent were followed-up during a period of one to eight years. A new classification is presented which is as follows: Episcleritis (217 eyes) Simple episcleritis (170 eyes) Nodular episcleritis (47 eyes) Scleritis (301 eyes) Diffuse anterior scleritis (I 19 eyes) Nodular anterior scleritis (134 eyes) Necrotizing scleritis (42 eyes). Of these, 13 were regarded as scleromalacia perforans. Posterior scleritis (6 eyes) The diagnosis is based on an exact clinical examination which is fully described. Episcleritis has been shown to be a benign recurring condition, a mild keratitis being the only occasional complication. Episcleritis does not progress to scleritis, except in the case of herpes zoster which sometimes starts as an episcleritis with the vesicular stage of the eruption, to reappear three months later as a scleritis in the same site. No clear conclusions could be drawn as to the aetiology of episcleritis. Scleritis is always accompanied by episcleral inflammation which must be ignored in making the diagnosis. Scleritis is a much more severe disease than episcleritis, leading to loss of visual acuity from corneal changes, uveitis, cataract, or retinal detachment if not treated. Necrotizing scleritis with inflammation is the severest form of the disease and 21 per cent of the patients with this condition died within the eight-year-period of follow-up. Connective-tissue disease was the commonest associated general condition; the incidence of necrotizing scleritis was higher in this group and 21 per cent of these patients were among those that died. It is probable that necrotizing scleritis represents the eye changes of the malignant phase of systemic connective-tissue disease. Treatment is unnecessary in episcleritis but in scleritis systemic treatment with anti-inflammatory agents or corticosteroids is obligatory. Using these routines of treatment only three patients (o-6 per cent) have lost an eye. Apart from ourselves, the following have worked in the Scleritis Clinic during the past io years: A. Atkinson, P. Awdry, P. E. Cleary, R. S. Clemett, P. Fowler, A. Freedman, B. Hazleman, P. Henderson, A. D. Holt-Wilson, D. Jones, S. Lachmann, D. Lloyd-Jones, D. Lobascher, A. J. Lyne, and D. A. R. Mackay, and we would like to thank them all for their help and ideas. We are sure many of these ideas are incorporated in this article but it is impossible to acknowledge them properly because we have forgotten where they originated. We should also like to thank all those surgeons who have referred patients to us: without them there would be no clinic. The computer analysis was completed at the Institute of Ophthalmology and many of the illustrations were reproduced there; the rest were done in the Medical Illustration Department of Addenbrooke's Hospital, Cambridge. Figs 6 and 14 were reproduced from the Transactions of the Ophthalmological Society of the United Kingdom; Fig. 16 from Connective-tissue disease in the eye, in Recent Advances in Ophthalmology, ed. P. Trevor-Roper, published by Blackwell; and Fig. 20 from the British Journal of Ophthalmology. Last but not least we should like to thank all those who have at various times typed part or all of this manuscript, in particular Mrs J. Field and Mrs J. McCombie.