Nodular scleritis

Nodular scleritis consists of one or more focal nonmovable nodules of inflamed scleral tissue (Figure 28-5), usually in the interpalpebral region. These nodules are frequently tender to palpation, and nodular scleritis is more likely to cause severe or radiating pain than diffuse scleritis. 

Figure 28-5 Focal scleral and episcleral inflammation seen in nodular scleritis.

Topical ocular steroids are often not effective alone in treating scleritis however, up to 47% of patients with diffuse or nodular scleritis may recover with only 1% topical prednisolone acetate. Therefore, topical steroids may be appropriate in treating mild inflammation and pain, to maintain a state of remission between exacerbations, and as adjunctive therapy to oral agents.Topical cyclosporine A may also be effective in treatment of scleritis, either alone or as an adjunctive agent to systemic treatment. 

Posterior scleritis is a special, locally confined type of idiopathic inflammation of the orbit, which presents clinically with slowly progressive, painful proptosis. Cross-sectional imaging shows diffuse thickening of the sclera and inflammation of adjacent tissue, with marked contrast uptake. As differential diagnoses, nodular scleritis does not show with contrast uptake, while uveal melanoma does take up contrast media, but usually delineates well (Mueller-Forell and Pitz 2004). 

Episcleritis is clinically classified as either simple or nodular. Simple episcleritis is usually the milder form, being limited to a sector of the eye in approximately two-thirds of cases, but can affect the entire episclera in approximately one-third of cases. Nodnlar episcleritis is nsually more serious and involves the presence of a definitive nodule and mild to moderate discomfort. Approximately 20% to 25% of cases present as nodular. Only 2% to 5% of episcleritis progresses to scleritis. Simple episcleritis usually lasts 1 to 3 weeks, whereas nodular episcleritis has a more variable course, in some cases lasting up to 2 months. Both forms periodically recnr but become less frequent with time until the disease no longer remits. Either form may recur as the other. 

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