Skip to main content

Advertisement

SpringerLink
Log in

Infectious Scleritis

  • Ocular Therapy (B. Jeng, Section Editor)
  • Published:
Current Ophthalmology Reports Aims and scope Submit manuscript

Abstract

Scleritis is a rare but painful, indolent, locally destructive, and devastating disease of the sclera. While immune-mediated scleritis with or without systemic association forms a vast majority of the cases seen in the clinics, approximately 5–18 % of all cases of scleritis can be due to infectious process. The challenges in the diagnosis and management of infectious scleritis are multiple. The diagnosis is often delayed due to the close similarity of clinical presentation between non-infectious and infectious etiology, and also because the clinical signs of infection may be obvious only in the late stages. In addition, the use of corticosteroids in presumed non-infectious scleritis further complicates the management. Microbiological diagnosis is often elusive as the organisms lie deep within the scleral layers and repeated biopsy is sometimes required for its identification. These microbes can be indolent in nature and traditional testing to detect them may not suffice. The management of infectious scleritis is fraught with multiple hurdles. In the case of medical management, the avascular scleral tissue has poor penetration of topically applied medications—especially antifungal agents, necessitating additional parenteral therapy for prolonged periods. Surgical modalities such as debridement of infected and necrotic tissue are mandatory. In this review, we describe the clinical features, differential diagnosis, and microbiological spectrum of infectious scleritis. This review also highlights the medical and surgical management of this difficult entity and will provide a comprehensive literature review of this disease.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. • Jain V, Garg P, Sharma S. Microbial scleritis—experience from a developing country. Eye (Lond). 2009;23:255–61. This is an important reference as it highlights fungal and Nocardia scleritis as being associated with poorer outcomes.

    Article  CAS  Google Scholar 

  2. Moriarty AP, Crawford GJ, McAllister IL, Constable IJ. Severe corneoscleral infection. A complication of beta irradiation scleral necrosis following pterygium excision. Arch Ophthalmol. 1993;111:947–51.

    Article  CAS  PubMed  Google Scholar 

  3. Reynolds MG, Alfonso E. Treatment of infectious scleritis and keratoscleritis. Am J Ophthalmol. 1991;112:543–7.

    Article  CAS  PubMed  Google Scholar 

  4. Hemady R, Sainz de la Maza M, Raizman MB, Foster CS. Six cases of scleritis associated with systemic infection. Am J Ophthalmol. 1992;114:55–62.

    Article  CAS  PubMed  Google Scholar 

  5. Wilhelmus KR, Yokoyama CM. Syphilitic episcleritis and scleritis. Am J Ophthalmol. 1987;104:595–7.

    Article  CAS  PubMed  Google Scholar 

  6. Maskin SL. Infectious scleritis after a diabetic foot ulcer. Am J Ophthalmol. 1993;115:254–5.

    Article  CAS  PubMed  Google Scholar 

  7. Ormerod LD, Puklin JE, McHenry JG, McDermott ML. Scleral flap necrosis and infectious endophthalmitis after cataract surgery with a scleral tunnel incision. Ophthalmology. 1993;100:159–63.

    Article  CAS  PubMed  Google Scholar 

  8. Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol. 1976;60:163–91.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  9. •• Hodson KL, Galor A, Karp CL, Davis JL, Albini TA, Perez VL, et al. Epidemiology and visual outcomes in patients with infectious scleritis. Cornea. 2013;32:466–72. In this study, the authors have presented a large series of infectious scleritis and have identified factors associated with a poor visual prognosis.

    Article  PubMed  Google Scholar 

  10. •• Reddy JC, Murthy SI, Reddy AK, Garg P. Risk factors and clinical outcomes of bacterial and fungal scleritis at a tertiary eye care hospital. Middle East Afr J Ophthalmol. 2015;22:203–11. In this study, the authors have compared the clinical outcomes and described the treatment modalities of various etiological types of infectious scleritis.

    Article  PubMed Central  PubMed  Google Scholar 

  11. •• Ho YF, Yeh LK, Tan HY, Chen HC, Chen YF, Lin HC, Chen SY, Hui-Kang D, Hsiao CH. Infectious scleritis in Taiwan-a 10-year review in a tertiary-care hospital. Cornea. 2014;33(8):838–43. This study presents the clinical features of infectious scleritis with distinct inciting events and provides and analysis of the factors associated with poor visual outcome.

    Article  PubMed  Google Scholar 

  12. Hsiao CH, Chen JJ, Huang SC, et al. Intrascleral dissemination of infectious scleritis following pterygium excision. Br J Ophthalmol. 1998;82:29–34.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  13. Huang FC, Huang SP, Tseng SH. Management of infectious scleritis after pterygium excision. Cornea. 2000;19:34–9.

    Article  CAS  PubMed  Google Scholar 

  14. Su CY, Tsai JJ, Chang YC, et al. Immunologic and clinical manifestations of infectious scleritis after pterygium excision. Cornea. 2006;25:663–6.

    Article  PubMed  Google Scholar 

  15. Lin CP, Shih MH, Tsai MC. Clinical experiences of infectious scleral ulceration: a complication of pterygium operation. Br J Ophthalmol. 1997;81:980–3.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  16. Meallet MA. Subpalpebral lavage antibiotic treatment for severe infectious keratitis and scleritis. Cornea. 2006;25(2):159–63.

    Article  CAS  PubMed  Google Scholar 

  17. Kumar Sahu S, Das S, Sharma S, et al. Clinico-microbiological profile and treatment outcome of infectious scleritis: experience from a tertiary eye care center of India. Int J Inflamm. 2012;2012:753–60.

    Article  Google Scholar 

  18. Murthy SI, Sati A, Sangwan VS. Infectious scleritis mimicking severe ocular inflammation: atypical initial presentation. BMJ Case Rep. 2013. doi:10.1136/bcr2013-008686.

    Google Scholar 

  19. Altman AJ, Cohen EJ, Berger ST, Modino BJ. Scleritis and streptococcus pneumonia. Cornea. 1991;10(4):341–5.

    Article  CAS  PubMed  Google Scholar 

  20. Margo CE, Pavan PR. Mycobacterium chelonae conjunctivitis and scleritis following vitrectomy. Arch Ophthalmol. 2000;118(8):1125–8.

    Article  CAS  PubMed  Google Scholar 

  21. Lyne AJ, Llyod-Jones D. Necrotizing scleritis after ocular surgery. Trans Ophthalmol Soc UK. 1979;99(1):146–9.

    CAS  PubMed  Google Scholar 

  22. Moorthy RS, Valluri S, Rao NA. Nontuberculous mycobacterial ocular infection. Surv Ophthalmol. 2012;57:202–35.

    Article  PubMed  Google Scholar 

  23. Pope J Jr, Sternberg P Jr, McLane NJ, et al. Mycobacterium chelonae scleral abscess after removal of a scleral buckle. Am J Ophthalmol. 1989;107:557–8.

    Article  PubMed  Google Scholar 

  24. Smiddy WE, Miller D, Flynn HW Jr. Scleral buckle infections due to atypical mycobacteria. Retina. 1991;11:394–8.

    CAS  PubMed  Google Scholar 

  25. Metta H, Corti M, Brunzini R. Disseminated infection due to Mycobacterium chelonae with scleritis, spondylodiscitis and spinal epidural abscess. Braz J Infect Dis. 2008;12(3):260–2.

    Article  PubMed  Google Scholar 

  26. Kesen MR, Edwards DP, Rao NA, et al. Atypical infectious nodular scleritis. Arch Ophthalmol. 2009;127(8):1079–80.

    Article  PubMed  Google Scholar 

  27. Sahu SK, Sharma S, Das S. Nocardia scleritis—clinical presentation and management: a report of three cases and review of literature. Ophthalmic Inflamm Infect. 2012;2(1):7–11.

    Article  Google Scholar 

  28. Sridhar MS, Gopinathan U, Garg P, Sharma S, Rao GN. Ocular nocardia infections with special emphasis on the cornea. Surv Ophthalmol. 2001;45:361–78.

    Article  CAS  PubMed  Google Scholar 

  29. Brooks JGJ, Mills RAD, Coster DJ. Nocardial scleritis. Am J Ophthalmol. 1992;114:371–2.

    Article  PubMed  Google Scholar 

  30. Holland SP, Pulido JS, Miller D, Ellis B, Alfonso E, Scott M, Costerton JW. Biofilm and scleral buckle-associated infections: a mechanism for persistence. Ophthalmol. 1991;98:933–8.

    Article  CAS  Google Scholar 

  31. King LP, Furlong WB, Gilbert WS, Levy C. Nocardia asteroids infection following scleral buckling. Ophthalmic Surg. 1991;22:150–2.

    CAS  PubMed  Google Scholar 

  32. Knox CM, Whitcher JP, Cevellos V, Margolis TP, Irvine AR. Nocardia scleritis. Am J Ophthalmol. 1997;123:713–4.

    Article  CAS  PubMed  Google Scholar 

  33. Ramos-Esteban JC, Servat JJ, Silva RS, et al. Necrotizing nocardial scleritis after combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation: a case report and review of the literature. Arq Bras Oftalmol. 2007;70:355–9.

    Article  PubMed  Google Scholar 

  34. Seth RK, Gaudio PA. Nocardia asteroides necrotizing scleritis associated with subtenon triamcinolone acetonide injection. Ocul Immunol Inflamm. 2008;16:139–40.

    Article  PubMed  Google Scholar 

  35. Basti S, Gopinathan U, Gupta S. Nocardial necrotizing scleritis after trauma. Cornea. 1994;13:274–5.

    Article  CAS  PubMed  Google Scholar 

  36. Sridhar MS, Cohen EJ, Rapuano CJ, Lister MA, Liabson PR. Nocardia asteroides sclerokeratitis in a contact lens wearer. CLAO J. 2002;28:66–8.

    CAS  PubMed  Google Scholar 

  37. Rush RB. Contact lens-associated nocardial necrotizing scleritis. Korean J Ophthalmol. 2013;27:291–3.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Das S, Saunders M, Cheng AC, Whiting M. Nodular non-necrotising anterior scleritis due to nocardia nova infection. Eye (Lond). 2007;21:276–8.

    Article  CAS  PubMed  Google Scholar 

  39. Choudhry S, Rao SK, Biswas J, Madhavan HN. Necrotizing nocardial scleritis with intraocular extension: a case report. Cornea. 2000;19:246–8.

    Article  CAS  PubMed  Google Scholar 

  40. Okhravi N, Odufuwa B, McCluskey P, et al. Scleritis. Surv Opthalmol. 2005;50:351–63.

    Article  Google Scholar 

  41. • Gonzalez-Gonzalez LA, Molina-Prat N, Doctor P, Tauber J, Sainz de la Maza MT, Foster CS. Clinical features and presentation of infectious scleritis from herpes viruses: a report of 35 cases. Ophthalmology. 2012;119:1460–4. This is a larger retrospective series that studied the clinical features and ocular complications of this subset of patients with herpetic scleritis.

    Article  PubMed  Google Scholar 

  42. Nguyen P, Yiu SC. Imaging studies in a case of infectious scleritis after pterygium excision. Middle East Afr J Ophthalmol. 2012;19(3):337–9.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  43. Doshi RR, Harocopos GJ, Schwab IR, et al. The spectrum of postoperative scleral necrosis. Surv Ophthalmol. 2013;58:620–33.

    Article  PubMed  Google Scholar 

  44. Raber IM, Laibson PR, Kurz GH, Bernardino VB. Pseudomonas corneoscleral ulcers. Am J Ophthalmol. 1981;92:353–63.

    Article  CAS  PubMed  Google Scholar 

  45. Farell PLR, Smith RE. Bacterial corneoscleritis complicating pterygium excision. Am J Ophthalmol. 1989;107:515–7.

    Article  Google Scholar 

  46. Sykes SO, Riemann C, Santos CI, et al. Haemophilus influenza associated scleritis. Br J Ophthalmol. 1999;83:410–3.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  47. Chen YF, Chung PC, Hsiao CH. Stenotrophomonas maltophilia keratitis and scleritis. Chang Gung Med J. 2005;28:142–50.

    PubMed  Google Scholar 

  48. Hwang YS, Chen YF, Lai CC, et al. Infectious scleritis after use of immunomodulators. Arch Ophthalmol. 2002;120:1093–4.

    PubMed  Google Scholar 

  49. Lee SB, Kim KS, Lee WK, Kim YJ, Kang MW. Ocular syphilis characterised by severe scleritis in a patient infected with HIV. Lancet Infect Dis. 2013;13:994.

    Article  PubMed  Google Scholar 

  50. Bhat PV, Jakobiec FA, Kurbanyan K, Zhao T, Foster CS. Chronic herpes simplex scleritis: characterization of 9 cases of an under recognized clinical entity. Am J Ophthalmol. 2009;148:779–89.

    Article  PubMed  Google Scholar 

  51. Naseri A, Good WV, Cunningham ET Jr. Herpes zoster virus sclerokeratitis and anterior uveitis in a child following varicella vaccination. Am J Ophthalmol. 2003;135:415–7.

    Article  PubMed  Google Scholar 

  52. Livir-Rallatos C, El-Shabrawi Y, Zatirakis P, Pellett PE, Stamey FR, Foster CS. Recurrent nodular scleritis associated with varicella zoster virus. Am J Ophthalmol. 1998;126:594–7.

    Article  CAS  PubMed  Google Scholar 

  53. Mietz H, Franzen C, Hoppe T, Bartz-Schmidt KU. Microsporidia-induced sclerouveitis with retinal detachment. Arch Ophthalmol. 2002;120:864–5.

    PubMed  Google Scholar 

  54. Iovieno A, Gore DM, Carnt N, Dart JK. Acanthamoeba sclerokeratitis: epidemiology, clinical features, and treatment outcomes. Ophthalmology. 2014;121:2340–7.

    Article  PubMed  Google Scholar 

  55. Arnalich-Montiel F, Jaumandreu L, Leal M, Valladares B, Lorenzo-Morales J. Scleral and intraocular amoebic dissemination in Acanthamoeba keratitis. Cornea. 2013;32:1625–7.

    Article  PubMed  Google Scholar 

  56. Kamath YS, Rathinam SR, Kawali A. Ocular toxoplasmosis associated with scleritis. Indian J Ophthalmol. 2013;61:295–7.

    Article  PubMed Central  PubMed  Google Scholar 

  57. • Tittler EH, Nguyen P, Rue KS, et al. Early surgical debridement in the management of infectious scleritis after pterygium excision. J Ophthalmic Inflamm Infect. 2012;2:81–7. This report highlights the importance of early surgical debridement in infectious scleritis and its role in resolution of the infection.

    Article  PubMed Central  PubMed  Google Scholar 

  58. Cunningham MA, Alexander JK, Matoba AY, et al. Management and outcome of microbial anterior scleritis. Cornea. 2011;30:1020–3.

    Article  PubMed Central  PubMed  Google Scholar 

  59. Pradhan ZS, Jacob P. Infectious scleritis: clinical spectrum and management outcomes in India. Indian J Ophthalmol. 2013;61:590–3.

    Article  PubMed Central  PubMed  Google Scholar 

  60. Chao DL, Albini TA, McKeown CA, Cavuoto KM. Infectious Pseudomonas scleritis after strabismus surgery. J AAPOS. 2013;17:423–5.

    Article  PubMed  Google Scholar 

  61. Zheng X, Kodama T, Goto T, Ohashi Y. Autologous fascia lata grafts for scleral repair in eyes with infectious necrotizing scleritis. Arch Ophthalmol. 2011;129:1225–7.

    Article  PubMed  Google Scholar 

  62. Hessburg PC. Pseudomonas corneoscleral ulcers. Am J Ophthalmol. 1982;93:256.

    Article  CAS  PubMed  Google Scholar 

  63. Harbin T. Recurrence of a corneal Pseudomonas infection after topical steroid therapy. Report of a case. Am J Ophthalmol. 1964;58:670–4.

    Article  CAS  PubMed  Google Scholar 

  64. Huang SC, Lai HC, Lai IC. The treatment of Pseudomonas keratoscleritis after pterygium excision. Cornea. 1999;18:608–11.

    Article  CAS  PubMed  Google Scholar 

  65. Kernacki KA, Goebel DJ, Poosch MS, Hazlett LD. Early cytokine and chemokine gene expression during Pseudomonas aeruginosa corneal infection in mice. Infect Immun. 1998;66:376–9.

    PubMed Central  CAS  PubMed  Google Scholar 

  66. Vo RC, Stafeeva K, Aldave AJ, Stulting RD, Moore Q, Pflugfelder SC, Chungfat NC, Holsclaw DS, Margolis TP, Deng SX. Complications related to a cosmetic eye-whitening procedure. Am J Ophthalmol. 2014;158:967–73.

    Article  PubMed  Google Scholar 

  67. Smiddy WE, Miller D, Flynn HW Jr. Scleral buckle removal following retinal reattachment surgery: clinical and microbiologic aspects. Ophthalmic Surg. 1993;24:440–5.

    CAS  PubMed  Google Scholar 

  68. Feiz V, Redline DE. Infectious scleritis after pars plana vitrectomy because of methicillin-resistant Staphylococcus aureus resistant to fourth-generation fluoroquinolones. Cornea. 2007;26:238–40.

    PubMed  Google Scholar 

  69. Rich RM, Smiddy WE, Davis JL. Infectious scleritis after retinal surgery. Am J Ophthalmol. 2008;145:695–9.

    Article  PubMed  Google Scholar 

  70. Lee JE, Oum BS, Choi HY, Lee JS. Methicillin-resistant Staphylococcus aureus sclerokeratitis after pterygium excision. Cornea. 2007;26:744–6.

    Article  PubMed  Google Scholar 

  71. Paula JS, Simão ML, Rocha EM, Romão E, Velascocruz AA. Atypical pneumococcal scleritis after pterygium excision: case report and literature review. Cornea. 2006;25:115–7.

    Article  PubMed  Google Scholar 

  72. Lalitha P, Rathinam SR, Srinivasan M. Ocular infections due to non-tuberculous mycobacteria. Indian J Med Microbiol. 2004;22:231–7.

    CAS  PubMed  Google Scholar 

  73. Nielsen JS, Blatt S, Perlman JI, Gieser RG. Clinicopathologic case report: scleral buckle associated nontuberculous mycobacterial scleritis. Semin Ophthalmol. 2004;19:101–4.

    Article  PubMed  Google Scholar 

  74. Oz O, Lee DH, Smetana SM, Akduman L. A case of infected scleral buckle with Mycobacterium chelonae associated with chronic intraocular inflammation. Ocul Immunol Inflamm. 2004;12:65–7.

    Article  PubMed  Google Scholar 

  75. Caronia R, Liebmann J, Speaker M, Ritch R. Corynebacterium scleritis. Am J Ophthalmol. 1994;117:405–6.

    Article  CAS  PubMed  Google Scholar 

  76. Mihara E, Shimizu M, Touge C, Inoue Y. Case of a large, movable bacterial concretion with biofilm formation on the ocular surface. Cornea. 2004;23:513–5.

    Article  PubMed  Google Scholar 

  77. Accorinti M, Abbouda A, Gilardi M, Zito R, Iannetti L. Cytomegalovirus-related scleritis. Ocul Immunol Inflamm. 2013;21:413–5.

    Article  PubMed  Google Scholar 

  78. Furukawa H, Hamada T, Nagaya K, Akiya S, Hamada T. A case of necrotizing scleritis associated with Epstein–Barr virus infection. Nihon Ganka Gakkai Zasshi. 1993;97:1337–42.

    CAS  PubMed  Google Scholar 

  79. Kamoi K, Mochizuki M. HTLV infection and the eye. Curr Opin Ophthalmol. 2012;23:557–61.

    Article  PubMed  Google Scholar 

  80. Kedhar SR, Belair ML, Jun AS, Sulkowski M, Thorne JE. Scleritis and peripheral ulcerative keratitis with hepatitis C virus-related cryoglobulinemia. Arch Ophthalmol. 2007;125:852–3.

    Article  PubMed  Google Scholar 

  81. Reddy AK, Garg P, Babu KH, Gopinathan U, Sharma S. In vitro antibiotic susceptibility of rapidly growing nontuberculous mycobacteria isolated from patients with microbial keratitis. Curr Eye Res. 2010;35:225–9.

    Article  CAS  PubMed  Google Scholar 

  82. Helm CJ, Holland GN, Webster RG Jr, Maloney RK, Mondino BJ. Combination intravenous ceftazidime and aminoglycosides in the treatment of pseudomonal scleritis. Ophthalmology. 1997;104:838–43.

    Article  CAS  PubMed  Google Scholar 

  83. Brown SI, Weller CA, Vidrich AM. Effect of corticosteroids on corneal collagenase of rabbits. Am J Ophthalmol. 1970;70:744–7.

    Article  CAS  PubMed  Google Scholar 

  84. Lalitha P, Tiwari M, Prajna NV, Gilpin C, Prakash K, Srinivasan M. Nocardia keratitis: species, drug sensitivities, and clinical correlation. Cornea. 2007;26:255–9.

    Article  PubMed  Google Scholar 

  85. Prajna NV, Anitha M, Divya R, George C, Srinivasan M. Effect of topical 0.02 % polyhexamethylene biguanide on nocardial keratitis associated with scleritis. Indian J Ophthalmol. 1998;46:251–2.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Cornea and Anterior Segment Service, Center for Ocular Regeneration (CORE), Srujana-Center for Innovation, L V Prasad Eye Institute, Kallam Anji Reddy Campus, L.V. Prasad Marg, Banjara Hills, Hyderabad, 500 034, India

    Somasheila I. Murthy, Jagadesh C. Reddy & Virender S. Sangwan

  2. Jhaveri Microbiology Center, L V Prasad Eye Institute, Kallam Anji Reddy Campus, L.V. Prasad Marg, Banjara Hills, Hyderabad, 500 034, India

    Savitri Sharma

Authors
  1. Somasheila I. Murthy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jagadesh C. Reddy
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Savitri Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Virender S. Sangwan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Virender S. Sangwan.

Ethics declarations

Disclosures

The authors declare their no conflicts of interests to report.

Human and Animal Rights and Informed Consent

This article contains no studies with human or animal subjects performed by the author.

Additional information

This article is part of the Topical Collection on Ocular Therapy.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Murthy, S.I., Reddy, J.C., Sharma, S. et al. Infectious Scleritis. Curr Ophthalmol Rep 3, 147–157 (2015). https://doi.org/10.1007/s40135-015-0079-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40135-015-0079-3

Keywords

Search

Navigation