Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Scleritis

Scleritis is a serious, often painful inflammation of the sclera that can cause permanent loss of vision in severe cases [S1]. Most cases are immune mediated, and 30%-40% of patients have an underlying systemic autoimmune condition [S1]; rheumatoid arthritis and granulomatosis with polyangiitis (GPA) are the commonest associations of necrotising scleritis [S11]. A minority are infectious, and steroids given for presumed immune scleritis can spread the infection, so telling the two apart is critical [S6].

Key points - Subtypes are diffuse anterior, nodular anterior, necrotising and posterior scleritis [S9]; necrotising scleritis is the most destructive form [S11]. - Every patient needs a thorough systemic evaluation; scleritis may be the first sign of GPA or rheumatoid arthritis [S1]. - Infectious scleritis makes up 5%-10% of cases and needs directed antimicrobial therapy [S4]; test for syphilis [S12]. - Oral NSAIDs and oral corticosteroids are first-line for non-infectious scleritis; refractory cases need antimetabolites, T-cell inhibitors or biologics (expert opinion) [S2]. - Most treatment decisions rest on observational data; no head-to-head or refractory-case RCTs exist [S5].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Necrotising scleritis. Highest complication rates, with more secondary glaucoma and cataract than other forms [S11].
• Scleritis after eye surgery. Surgery is the commonest risk factor for infectious necrotising scleritis, most often caused by Pseudomonas [S11].
• Worsening on corticosteroids. Consider infection; steroids can propagate it [S6].
• Possible GPA: ocular involvement in GPA includes scleritis, orbital mass, dacryocystitis and keratitis [S10].
• Posterior scleritis. It can be sight-threatening and may cause choroidal folds, effusion and exudative retinal detachment [S8].

Recognise it

• Symptoms and signs. Focal or diffuse hyperaemia, moderate to severe pain and frequent visual impairment [S4]; severe ocular pain and tissue destruction [S6].
• Course. Acute monophasic, relapsing-remitting or chronic [S1].
• Episcleritis vs scleritis. Prompt discrimination matters because management, prognosis and complications differ [S3].
• Associations. Rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematosus and GPA [S9]; ANCA-associated vasculitis and IgG4-related disease [S5]. About half of patients have no identifiable cause [S1].
• Posterior scleritis can involve the choroid: increased thickness, choroidal vasculitis, a choroidal or subretinal mass, choroidal folds, effusion or exudative detachment [S8].

Confirm it

• Systemic work-up guided by careful history and examination [S3]; all patients require thorough systemic evaluation [S1].
• ANCA serology supports a diagnosis of GPA together with imaging and biopsy [S10].
• Syphilis testing for every patient with scleritis or episcleritis is important, given rising global incidence [S12].
• Suspected infection: culture or biopsy; Nocardia was diagnosed on excisional biopsy of a scleral nodule in one case [S4].
• Posterior scleritis: multimodal imaging helps diagnosis and monitoring [S8].

Manage it

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Tier A (primary care / no specialist)

• Severe eye pain with redness or reduced vision, especially in a patient with rheumatoid arthritis or vasculitis, needs eye specialist assessment (timing in the table below) [S1] [S5].
• Do not start steroid eye drops or oral steroids before infection has been considered; steroids can spread infectious scleritis [S6].

Tier B (general eye clinic)

1. Classify the subtype and look for necrosis [S9] [S11].
2. Exclude infection, including syphilis [S6] [S12].
3. First-line for non-necrotising, non-infectious disease: oral NSAIDs [S9]; local subconjunctival steroid injection is an option for non-necrotising scleritis [S1]. Systemic corticosteroids are used when needed [S2]. Doses are not covered by these abstracts: follow local formularies.
4. Treat the underlying disease with the rheumatology team [S5] [S9].

Tier C (specialist centre)

1. Non-infectious necrotising scleritis requires aggressive combination immunosuppressive therapy [S11]. Timely immunosuppressive treatment reduces ocular and systemic morbidity [S1].
2. Refractory disease: antimetabolites, calcineurin inhibitors, biologics and alkylating agents [S9]. Rituximab, usually as third-line or later, gave a positive response in 93.3% of 120 scleritis cases in a pooled case review (mostly GPA, 62.0%); no side effects were reported in 85.5% of scleritis cases [S7]. The most used regimen was two infusions of 1 g separated by 14 days (as reported in [S7]).
3. Infectious scleritis needs long-term antimicrobials and often surgical debridement, drainage and patch grafting [S11]. Syphilitic scleritis usually responds to antibiotics rapidly, often within 1 week; almost one-quarter of reported patients had HIV co-infection [S12].

Refer when

Pitfalls

• Giving corticosteroids for infectious scleritis [S6].
• Missing syphilis; initial misdiagnosis delayed antibiotics in reported cases [S12].
• Treating scleritis as an eye-only disease; it can precede systemic vasculitis [S5].
• Confusing episcleritis with scleritis [S3].

Evidence notes

• Thin evidence. All sources are reviews or case-based syntheses; most therapeutic decisions rest on observational data, and RCTs are lacking [S5].
• The rituximab figures pool published case data without a control group [S7].
• Not covered by these sources: NSAID and steroid doses, scleral imaging with ultrasound in low-resource settings, and outcomes by subtype.

Related articles

• Anterior Uveitis
• The red eye: triage
• Idiopathic Orbital Inflammation and IgG4-Related Orbital Disease

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.