3.1.7.2 General Eye Examination

Episcleritis and scleritis can appear as isolated lesions or can be accompanied by other ocular manifestations. These manifestations can appear as a complication of the inßammatory process itself or concomitantly with the scleral disease. Complications of episcleritis and scleritis include extraocular muscle involvement, keratitis, uveitis, cataract, glaucoma, disk edema, and macular edema. Concomitant manifestations of episcleritis and scleritis include any other ocular abnormalities present as part of the same systemic inßammatory disease that can also affect the sclera. In fact, many of the episcleritisand scleritis-associated systemic diseases may involve other ocular structures, such as the extraocular muscles, eyelids, conjunctiva, cornea, anterior and posterior uvea, retina, and optic nerve (Table 3.6). Because involvement of some of these structures is an important reason

for loss of vision and destruction of the eye, a complete general eye examination must never be omitted.

Visual Acuity

Visual acuity may be reduced in patients with scleritis, but almost never is in patients with episcleritis. The whole object of early diagnosis is early, appropriate treatment to prevent impaired vision. A further reduction in vision most frequently is due to the extension of the scleral inßammation to adjacent structures leading to keratitis, anterior uveitis, cataract, posterior uveitis, retinal detachment, optic neuritis, or glaucoma. The most common method of visual acuity measurement is the Snellen eye chart. The Snellen eye chart tests the ability of the eye to resolve high-contrast targets. The best corrected visual acuity, tested either by refraction or at least by pinhole, must be documented. Improvement or wors-

Fig. 3.21 Corneal examination may disclose peripheral stromal inÞltration associated with scleritis

Fig. 3.22 Peripheral corneal ulcer in a patient with diffuse anterior scleritis (slit-lamp photomicrograph). Note the presence of a peripheral corneal ulcer extending from approximately 3:30 clockwise to 8:30

ening of the patientÕs vision without evidence of other ocular complications can be critically useful in monitoring the effect of medical therapy.

Pupils and Extraocular Muscles

The standard measurements of the direct and consensual pupillary reaction to light, and the swinging ßashlight to detect a Marcus Gunn or reverse Marcus Gunn pupil can be helpful in assessing the status of the optic nerve. The optic nerve can be affected by sustained high intraocular pressure, direct spread of posterior scleral inßammation, long-standing posterior uveitis, or the same systemic diseases that may affect the sclera. For example, detection of an Argyll Robertson pupil, that is, a pupil that does not react to light but does react to convergence, in the presence of scleral inßammation, obligates one to consider syphilis.

Reduction of extraocular muscle function may occur because of inßammatory inÞltration or edema of a muscle secondary to surrounding scleral inßammation or because of III, IV, or VI cranial nerve palsies due to direct involvement of the nerve supply in the orbit by some systemic diseases that may also affect sclera.

Cornea

Careful slit-lamp examination of the cornea should always be performed because corneal involvement may occur in almost one-third of the

patients who develop scleritis. Corneal changes are primarily peripheral and adjacent to areas of scleral inßammation; therefore, they are usually more extensive in diffuse than in nodular scleritis. InÞltrates (Fig. 3.21), thinning, edema, neovascularization, and ulceration (Fig. 3.22) may result from the spread of the adjacent scleral inßammation. Several characteristic patterns of keratitis-associated scleritis have been described, ranging from a relatively benign thinning to a progressive, destructive, peripheral ulcerative keratitis that can lead to perforation and eventual loss of the eye. Early detection of corneal involvement may lead to adequate treatment, which may improve the ocular prognosis.

Because many scleritis-associated systemic diseases may also involve the peripheral cornea, scleral and corneal changes may be caused by the same immunological mechanisms.

Mild corneal changes occur in a small minority of patients with episcleritis, but they do not become permanent.

Anterior Uvea

Anterior chamber examination with the slit-lamp beam may reveal an anterior uveitis characterized by a mild-to-moderate amount of ßare and cells in the aqueous and anterior vitreous with a few small endothelial keratic precipitates. Mild anterior uveitis may be found in a small percentage of cases of episcleritis. Scleritis-associated