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      Clinical characteristics and visual outcomes in infectious scleritis: a review

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          Abstract

          Infection is a very important but rare cause of scleritis, occurring in about 5%–10% of all patients presenting with scleral inflammation. However, due to the similarity of its presentation, infectious scleritis is often initially managed as autoimmune, potentially further worsening its outcome. The overall visual outcome in infectious scleritis is generally worse than its autoimmune counterparts, perhaps because of the delay in diagnosis or because of the aggressive nature of associated microbes. Thus, there is a definite need for insight into the diagnostic approach and treatment options for this ocular disease process. Several studies and case reports have been published in recent years that have provided useful information regarding the presenting clinical features and etiologic microbial agents in infectious scleritis. This review summarizes the important findings in the literature that may aid in differentiating infectious scleritis from other etiologies, including predisposing factors, microbe-specific characteristics, diagnostic tools, treatment modalities, and outcomes.

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          Most cited references46

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          Clinical characteristics of a large cohort of patients with scleritis and episcleritis.

          To evaluate the demographic characteristics, clinical features, ocular complications, and disease associations of patients with scleritis and episcleritis; as well as to delineate the risk factors for decreased vision in patients with scleritis. Retrospective case series. Five hundred patients with scleritis and 85 patients with episcleritis. The electronic health records of 500 patients with scleritis and 85 patients with episcleritis seen at 2 tertiary referral centers were reviewed and their clinical features were studied. Clinical features (pain, scleral inflammation), ocular complications (decrease in vision, anterior uveitis, peripheral ulcerative keratitis, ocular hypertension), and disease associations. In a series of 585 patients, 500 patients had scleritis (85.5%) and 85 patients had episcleritis (14.2%). Ocular complications were more frequent overall in patients with scleritis versus in those with episcleritis (45.0% vs. 19.0%), including decrease in vision (15.8% vs. 2.3%), anterior uveitis (26.4% vs. 16.5%), peripheral ulcerative keratitis (7.4% vs. 0%), and ocular hypertension (14.2% vs. 3.5%; P<0.0001 for each). Disease association was observed in 35.8% of patients with scleritis versus 27.1% of episcleritis patients, including connective tissue or vasculitic diseases in 24.8% versus 15.3%, respectively. Scleritis preceded systemic disease diagnosis in 38.7% of patients. Ocular complications (90.0%) and disease association (80.0%) occurred most often in patients with necrotizing scleritis (P<0.0001 for each). Risk factors for decrease in vision in patients with scleritis included necrotizing scleritis (odds ratio [OR], 6.63; P<0.001), posterior scleritis (OR, 2.33; P = 0.042), degree of scleral inflammation of more than 2+ (range, 0-4+; OR, 3.60; P<0.001), anterior uveitis (OR, 1.78; P = 0.033), ocular hypertension (OR, 3.19; P<0.001), and associated disease (OR, 2.66; P<0.001), mainly infectious (OR, 4.44; P<0.001). Scleritis is associated more often with ocular complications than episcleritis, and necrotizing scleritis is the type of scleritis most often associated with ocular complications and disease association. Risk factors for decrease in vision in patients with scleritis include necrotizing scleritis, posterior scleritis, scleral inflammation of more than 2+, anterior uveitis, ocular hypertension, and associated infectious disease. The author(s) have no proprietary or commercial interest in any materials discussed in this article. Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
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            Scleritis and episcleritis.

            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 (119 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.
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              Microbial scleritis-experience from a developing country.

              The purpose of this article was to study the clinical features, pathogenic organisms, and the outcome in cases of infectious scleritis. Retrospective chart review of all patients of infectious scleritis examined from January 2000 to February 2005 in the cornea services of L.V. Prasad Eye Institute, Hyderabad, India was done. Information including patient's age, predisposing factors, clinical presentation, pathogenic organism, methods of diagnosis, treatment, and outcome were abstracted from the medical records. A total of 21 eyes of infectious scleritis were identified. All except three eyes had preceding predisposing factors, prior cataract surgery (6 eyes) (30%) and pterygium surgery (5 eyes) (23.8%) were the most common predisposing factors. Fungus (8 eyes) (38%), either alone (5 eyes) (24%) or as mixed infection (3 eyes) (14%), was the most common offending organism. Nocardia was identified in five eyes (24%) and Pseudomonas aeruginosa in two eyes (10%). Seven eyes (33%) had accompanying corneal infiltration. Multifocal scleral abscess was seen in three eyes (14%) and endophthalmitis was seen in three eyes (14%). During the course of treatment, five eyes (24%) were complicated by serous retinal or choroidal detachment and five eyes (24%) with progression of cataract. Surgical debridement was carried out in 14 eyes (67%). Four eyes (19%) were eviscerated. Useful vision, defined as visual acuity > or = 20/200, could be preserved with treatment in seven eyes (33%). Although predisposing factors were similar, fungi and Nocardia were the most common etiological agents in this series and the clinical outcomes were poorer.
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                Author and article information

                Journal
                Clin Ophthalmol
                Clin Ophthalmol
                Clinical Ophthalmology
                Clinical Ophthalmology (Auckland, N.Z.)
                Dove Medical Press
                1177-5467
                1177-5483
                2013
                2013
                04 November 2013
                : 7
                : 2113-2122
                Affiliations
                Department of Ophthalmology, George Washington University, Washington, DC, USA
                Author notes
                Correspondence: Emeline Radhika Ramenaden, Department of Ophthalmology, George Washington University, 2150 Pennsylvania Ave, NW, Suite 2A, Washington, DC 20037, USA, Tel +12027412800, Fax +12027412805, Email radhikar@ 123456gwmail.gwu.edu
                Article
                opth-7-2113
                10.2147/OPTH.S37809
                3821753
                24235809
                76fd7329-67e5-4855-b458-7553062f84d6
                © 2013 Ramenaden and Raiji. This work is published by Dove Medical Press Ltd, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Ltd, provided the work is properly attributed.

                History
                Categories
                Review

                Ophthalmology & Optometry
                infectious scleritis,pseudomonas,necrotizing scleritis,abscess
                Ophthalmology & Optometry
                infectious scleritis, pseudomonas, necrotizing scleritis, abscess

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