Bilateral syphilitic scleritis
C. Laboratory work-up for infectious and autoimmune disease
Topical phenylephrine is used to differentiate episcleritis from scleritis. Episcleritis causes congestion of superficial episcleral vessels, which constrict when exposed to phenylephrine, whereas scleritis causes congestion of deeper vessels, which are not significantly affected by phenylephrine.1
Scleritis is often associated with a systemic disease, so further investigation is recommended prior to starting treatment (choice C).2 Differential diagnosis includes autoimmune causes (rheumatoid arthritis, granulomatous polyangiitis, relapsing polychondritis, etc) and infections (syphilis, herpes viruses, etc).1,2 Work-up should be tailored to clinical presentation and review of systems and includes serum autoantibody testing (rheumatoid factor, antineutrophil cytoplasmic antibodies, antinuclear antibodies, etc), sarcoidosis screening, syphilis testing, urinalysis, and others.1- 3 Nodular and diffuse anterior scleritis often respond to oral nonsteroidal anti-inflammatory drugs (choice A).2 Corticosteroids (choice B) and systemic immunosuppression are recommended for patients who do not respond or necrotizing scleritis.1,3 Topical corticosteroids (choice D) can reduce inflammation, but systemic treatment is often required.1