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Abstract

Background
Scleritis belongs to the group of chronic inflammatory eye diseases that may cause ocular
hypertension (OHT) and secondary glaucoma (SG). Aim of this study was to identify the
incidence and risk factors for OHT and SG with regard to the scleritis form.
Methods
Single-center retrospective analysis of all consecutive patients with scleritis.
Results
A total of 271 scleritis patients (161 women, mean age 51.016.9 years) were enrolled. The
median follow-up was 17.021.4 months (range 6116). Of these patients, 56 (21 %)
showed an intraocular pressure (IOP) increase with an open chamber angle at any time
during follow-up. Another four patients (7 %) had secondary angle-closure glaucoma. An
increase in IOP was found more frequently in patients with necrotizing (42 %) than in those
with posterior (30 %), nodular (18 %) or diffuse anterior scleritis (18 %, p00.022). Most
patients (82 %) developed the pressure increase during acute scleritis episodes. Initially, 72
% of patients with increased IOP were classified as OHT; this figure had decreased to 56 % at
the end of follow-up. In the course of disease, the IOP normalized in 13 %. The univariate
analysis of risk factors showed an increased risk in the presence of anterior uveitis,
peripheral ulcerative keratitis, posterior synechiae, and previous cataract surgery.
Conclusions
An increase in IOP occurs in about one-fifth of patients with scleritis. The initial pressure
elevation occurs mostly in the acute phase of disease. An increase in pressure is found most
often in patients with necrotizing scleritis.
Introduction
Scleritis is a chronic inflammatory eye disease with a potentially poor clinical outcome [1].
As underlying, lifethreatening general condition can be associated, immunosuppressive
therapy may be indicated [2, 3]. Common secondary complications are scleral melting,
keratitis, cataract, and also elevated intraocular pressure (IOP) [4]. However, only a limited
number of studies have examined the incidence of glaucoma in scleritis patients [1, 39].
The pathogenesis of this pressure increase is not clearly defined in scleritis patients. In
addition to morphological changes in the trabecular outflow pathway, increased scleral or
episcleral vein pressures may be involved, or angle closure occurs due to serous retinal
detachment and rotated ciliary body [9, 10]. The aim of this study therefore was to examine
the incidence of secondary elevated IOP in a large group of scleritis patients, with a special
focus on different forms of scleritis and ocular hypertension and secondary open-angle or
angle-closure glaucoma. Furthermore, the time at first appearance of increased IOP and risk
factors for elevated IOP were assessed.
Patients and methods
All consecutive patients with scleritis seen in our clinic between 1999 and 2010 were
included and data were retrospectively analysed. The study design complies with the

standards put forth by the Declaration of Helsinki. Our institution does not require approval
from the local ethics committees for chart review studies.
The group of patients with elevated IOP comprised individuals with secondary ocular
hypertension (OHT) and secondary glaucoma (SG). OHT was defined as IOP elevation over
24 mmHg at two consecutive visits, according to the recommendations put forth for patients
with uveitis [11]. Patients who were on antiglaucomatous therapy without optic disc cupping
or visual field defects were classified as OHT. SG was defined by the presence of
glaucomatous optic neuropathy, a glaucomatous visual field defect, or both [11]. If both
eyes were affected by elevated IOP, only the eye with more severe inflammation activity
(number of flares, complications, and visual acuity) was included. If both eyes were similarly
affected, only the right eye was included in this analysis. If the two eyes were affected by
different forms of scleritis, again only the more severely afflicted eye was included. As
patients with pre-existing glaucoma or ocular hypertension were excluded from this study,
we had to exclude 15 patients.
Scleritis was diagnosed when typical signs of scleral inflammation and swelling of the scleral
tissue, including the superficial and deep episcleral vascular tissue, were observed [1]. The
various forms of scleritis were diagnosed in accordance with the classification put forth by
Watson and Hayreh [1]. Diagnosis of posterior scleritis was confirmed by B scan
ultrasonography [1, 12].
Statistical analysis was performed using MedCalc statistical software 10.0.1.0 (Marikerke,
Belgium). The chi-squared test was used for categorical values of complications, and the
Students t-test for linear values. For related values, flare and IOP in one patient, for
example, the paired t-test was applied. Univariate and multivariate regression analysis
performed to calculate odds ratio and 95 % confidence interval (CI). For multivariate
analysis, a stepwise backward logistic regression model was used. A significance level of 5 %
was set for all comparisons.