Download PDF
Augenheilkunde up2date 2023; 13(01): 9-24
DOI: 10.1055/a-1956-6246
Bindehaut, Hornhaut, Lederhaut

Diagnostisches und therapeutisches Management der Episkleritis und Skleritis

Diagnostic and Therapeutic Management of Episcleritis and Scleritis
Ferhat Turgut
,
Vita Dingerkus
,
Christoph Tappeiner
,
Matthias Becker
› Further Information
Also available at
    Permissions and Reprints All articles of this category

Zusammenfassung

Das schmerzhafte „rote Auge“ ist wohl das auffälligste Zeichen einer Augenerkrankung, hinter der milde, aber auch schwere Verläufe stecken können. Die Episkleritis und Skleritis sind hierbei wichtige Differenzialdiagnosen. Die rechtzeitige Diagnose ist nicht nur wichtig für die notwendige Therapie, sondern kann vor einer irreversiblen Visusminderung, einem Augenverlust sowie Organschäden schützen und ggf. sogar das Mortalitätsrisiko senken.

Abstract

While episcleritis is a benign disease only affecting the episclera, scleritis is an ocular inflammation with typically severe pain and not rarely affecting adjacent tissue.

Scleritis is classified into anterior and posterior forms. Anterior scleritis is further subdivided into diffuse, nodular, necrotizing with inflammation, and necrotizing scleritis without inflammation (scleromalacia perforans). A systemic disease such as rheumatoid arthritis or granulomatosis with polyangiitis is associated with up to 50% of all patients with scleritis or episcleritis, consequently a systemic work-up with blood sampling and imaging as well as collaboration with internists are necessary.

Differentiating these two entities is of high importance for planning the treatment: episcleritis has a self-limited course, whereas treatment of scleritis is obligatory to protect patients from irreversible visual loss, organ damage, and furthermore reduce the risk of mortality.

Treatment depending of subtype and associated systemic disease may involve non-steroidal anti-inflammatory drugs, corticosteroids, and disease-modifying anti-rheumatic drugs.

Kernaussagen

  • Die Episkleritis hat im Allgemeinen eine gute Prognose und ist deutlich seltener mit einer rheumatologischen Grunderkrankung assoziiert als die verschiedenen Skleritisformen.

  • Die nekrotisierende und die posteriore Skleritis stellen die bedrohlichsten Formen dar.

  • Die Gefahr der Skleritis betrifft nicht nur den Visus durch die mögliche Destruktion okulärer Strukturen, sondern besteht auch darin, dass sie als Zeichen einer organ- oder lebensgefährdenden Systemerkrankung auftreten kann. Schnelle, interdisziplinäre Diagnostik und Therapie ist daher maßgeblich.

  • Während bei der Episkleritis oft eine Lokaltherapie ausreichend ist, kommen bei der Skleritis praktisch immer systemische Therapien zum Einsatz, meist (bei unkomplizierter Form) NSAR, ansonsten Kortikosteroide oder/und immunsuppressive bzw. -modulierende Therapien.

  • Bei den steroidsparenden DMARD wird MTX am häufigsten angewandt. Biologika kommen bei unzureichendem Therapieansprechen auf csDMARD und bei nekrotisierender Skleritis oft bereits primär zum Einsatz.

Schlüsselwörter

Episkleritis - Skleritis - rheumatoide Arthritis - Granulomatose mit Polyangiitis - immunmodulatorische Therapie

Key words

Episcleritis - scleritis - ocular inflammation - rheumatoid arthritis - immunomodulatory therapy - granulomatosis with polyangiitis


Publication History

Article published online:
22 February 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Vergouwen DPC, Rothova A, Berge JCT. et al. Current insights in the pathogenesis of scleritis. Exp Eye Res 2020; 197: 108078
    CrossrefPubMedGoogle Scholar
  • 2 Tappeiner C, Walscheid K, Heiligenhaus A. [Diagnosis and treatment of episcleritis and scleritis]. Ophthalmologe 2016; 113: 797-810
    PubMedGoogle Scholar
  • 3 Thong LP, Rogers SL, Hart CT. et al. Epidemiology of episcleritis and scleritis in urban Australia. Clin Exp Ophthalmol 2020; 48: 757-766
    CrossrefPubMedGoogle Scholar
  • 4 Jakob E, Reuland MS, Mackensen F. et al. Uveitis subtypes in a german interdisciplinary uveitis center – analysis of 1916 patients. J Rheumatol 2009; 36: 127-136
    CrossrefPubMedGoogle Scholar
  • 5 Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol 1976; 60: 163-191
    CrossrefPubMedGoogle Scholar
  • 6 Ruiz-Lozano RE, Garza-Garza LA, Davila-Cavazos O. et al. The clinical and pathogenic spectrum of surgically-induced scleral necrosis: A review. Surv Ophthalmol 2021; 66: 594-611
    CrossrefPubMedGoogle Scholar
  • 7 McCluskey P, Wakefield D. Prediction of response to treatment in patients with scleritis using a standardised scoring system. Aust N Z J Ophthalmol 1991; 19: 211-215
    CrossrefPubMedGoogle Scholar
  • 8 Sen HN, Sangave AA, Goldstein DA. et al. A standardized grading system for scleritis. Ophthalmology 2011; 118: 768-771
    CrossrefPubMedGoogle Scholar
  • 9 Yu J, Syed ZA, Rapuano CJ. Infectious scleritis: Pathophysiology, diagnosis, and management. Eye Contact Lens 2021; 47: 434-441
    CrossrefPubMedGoogle Scholar
  • 10 Murthy SI, Sabhapandit S, Balamurugan S. et al. Scleritis: Differentiating infectious from non-infectious entities. Indian J Ophthalmol 2020; 68: 1818-1828
    CrossrefPubMedGoogle Scholar
  • 11 Braithwaite T, Adderley NJ, Subramanian A. et al. Epidemiology of scleritis in the United Kingdom from 1997 to 2018: Population-based analysis of 11 million patients and association between scleritis and infectious and immune-mediated inflammatory disease. Arthritis Rheumatol 2021; 73: 1267-1276
    CrossrefPubMedGoogle Scholar
  • 12 Maleki A, Ruggeri M, Colombo A. et al. B-Scan ultrasonography findings in unilateral posterior scleritis. J Curr Ophthalmol 2022; 34: 93-99
    CrossrefPubMedGoogle Scholar
  • 13 Magesan K, Surya J, Sridharan S. et al. Clinical profile of scleritis presenting for the first time in the elderly. Ocul Immunol Inflamm 2022; 1-5
    CrossrefPubMedGoogle Scholar
  • 14 Akpek EK, Uy HS, Christen W. et al. Severity of episcleritis and systemic disease association. Ophthalmology 1999; 106: 729-731
    CrossrefPubMedGoogle Scholar
  • 15 Smith JR, Mackensen F, Rosenbaum JT. Therapy insight: scleritis and its relationship to systemic autoimmune disease. Nat Clin Pract Rheumatol 2007; 3: 219-326
    CrossrefPubMedGoogle Scholar
  • 16 Kafkala C, Daoud YJ, Paredes I, Foster CS. Masquerade scleritis. Ocul Immunol Inflamm 2005; 13: 479-482
    CrossrefPubMedGoogle Scholar
  • 17 Axmann S, Ebneter A, Zinkernagel MS. Imaging of the sclera in patients with scleritis and episcleritis using anterior segment optical coherence tomography. Ocul Immunol Inflamm 2016; 24: 29-34
    CrossrefPubMedGoogle Scholar
  • 18 Watson PG, Bovey E. Anterior segment fluorescein angiography in the diagnosis of scleral inflammation. Ophthalmology 1985; 92: 1-11
    CrossrefPubMedGoogle Scholar
  • 19 Heiligenhaus A, Schilling M, Lung E, Steuhl KP. Ultrasound biomicroscopy in scleritis. Ophthalmology 1998; 105: 527-534
    CrossrefPubMedGoogle Scholar
  • 20 Vergouwen DPC, Ten Berge JC, Boukhrissi S. et al. Clinical relevance of autoantibodies and inflammatory parameters in non-infectious scleritis. Ocul Immunol Inflamm 2022; 30: 1859-1865
    CrossrefPubMedGoogle Scholar
  • 21 Bauer AM, Fiehn C, Becker MD. Celecoxib, a selective inhibitor of cyclooxygenase 2 for therapy of diffuse anterior scleritis. Am J Ophthalmol 2005; 139: 1086-1089
    CrossrefPubMedGoogle Scholar
  • 22 Jabs DA, Mudun A, Dunn JP, Marsh MJ. Episcleritis and scleritis: clinical features and treatment results. Am J Ophthalmol 2000; 130: 469-476
    CrossrefPubMedGoogle Scholar
  • 23 Agrawal R, Lee CS, Gonzalez-Lopez JJ. et al. A nonselective cyclooxygenase (COX) inhibitor for treatment of noninfectious, non-necrotizing anterior scleritis. Ocul Immunol Inflamm 2016; 24: 35-42
    CrossrefPubMedGoogle Scholar
  • 24 Roufas A, Jalaludin B, Gaskin C, McCluskey P. Subconjunctival triamcinolone treatment for non-necrotising anterior scleritis. Br J Ophthalmol 2010; 94: 743-747
    CrossrefPubMedGoogle Scholar
  • 25 Sohn EH, Wang R, Read R. et al. Long-term, multicenter evaluation of subconjunctival injection of triamcinolone for non-necrotizing, noninfectious anterior scleritis. Ophthalmology 2011; 118: 1932-1937
    CrossrefPubMedGoogle Scholar
  • 26 Kempen JH, Daniel E, Gangaputra S. et al. Methods for identifying long-term adverse effects of treatment in patients with eye diseases: the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study. Ophthalmic Epidemiol 2008; 15: 47-55
    CrossrefPubMedGoogle Scholar