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PubMed This is a summary of 19 peer-reviewed journal articles Updated
Ophthalmology

Subtypes, Biology, and Imaging of Scleritis

At a Glance

Scleritis is inflammation of the eye’s tough outer wall. Doctors classify it by location and severity, then use an eye examination and specialized scans to find hidden inflammation, tissue thinning, or disease behind the eye and guide treatment.

Scleritis is more than just a surface-level eye irritation; it is a complex immune-driven process that occurs within the deep, structural tissues of the eye globe. Understanding the biology and specific classification of your diagnosis is essential because your treatment plan depends on which “version” of the disease you have, its severity, and underlying causes [1].

The Biology of Scleritis

While the exact cause of non-infectious scleritis is still being studied, research points to immune mechanisms failing to distinguish between your own tissue and foreign invaders [1].

In a healthy eye, the sclera is a calm, white structure made of dense collagen. In scleritis, immune and inflammatory signals can damage scleral tissue. The body’s immune cells—such as macrophages, plasma cells, and B cells—infiltrate this tissue [2]. This can lead to several biological events:

  • Immune Complex Deposition: Proteins called antibodies can deposit in the scleral tissue, triggering an inflammatory response [3].
  • Inflammatory Signals: The immune cells release signaling proteins called cytokines, such as TNF (Tumor Necrosis Factor) and IL-6 (Interleukin-6) [2]. These act like chemical “alarms” that keep the inflammation active.
  • Tissue Destruction: Enzymes known as matrix metalloproteinases may be released, which can break down the collagen of the sclera, potentially leading to thinning or “melting” of the eye wall [3].

Classifying Your Diagnosis

Doctors use clinical categories to classify scleritis. This classification is vital because it tells your medical team how aggressive the treatment needs to be [4].

Anterior Scleritis (Front of the Eye)

This is the most common form, where the inflammation is visible on the white part of the eye [5].

  1. Diffuse Anterior: The most frequent type. Redness and swelling are spread broadly across the sclera [6].
  2. Nodular Anterior: The inflammation is localized into one or more firm, painful “bumps” (nodules) on the eye [7].
  3. Necrotizing with Inflammation: The most severe form. It causes “avascular” areas (spots where blood flow has stopped), leading to tissue death and rapid thinning [8][9].
  4. Necrotizing without Inflammation (Scleromalacia Perforans): A rare condition typically seen in patients with long-standing rheumatoid arthritis. The sclera thins significantly without the usual pain or redness [5][10].

Posterior Scleritis (Back of the Eye)

This affects the sclera behind the “equator” of the eye [4]. Because it is hidden from view, it can be difficult to diagnose without specialized imaging [11]. It often causes deep pain and can lead to vision loss by affecting the retina or optic nerve [12].

Diagnostic Imaging

Because the sclera is thick and opaque, doctors may use advanced technology to “see” the inflammation beneath the surface. Your doctor will select the appropriate imaging based on your symptoms.

  • AS-OCT (Anterior Segment Optical Coherence Tomography): This light-based scan allows doctors to measure the thickness of the sclera with extreme precision [13]. It can show intrascleral edema (fluid inside the eye wall) and help distinguish scleritis from the milder episcleritis [14][15].
  • UBM (Ultrasound Biomicroscopy): A high-resolution ultrasound that provides a detailed cross-section of the front of the eye, helping to identify nodules or early signs of thinning [16].
  • B-Scan Ultrasound: B-scan ultrasound is an important tool for diagnosing posterior scleritis [17]. The ultrasound can reveal fluid in “Tenon’s space” (a layer surrounding the eye). When this fluid collects around the optic nerve, it creates a characteristic shape on the screen known as the T-sign [18]. While a helpful clue, it is not required for diagnosis, and its absence does not rule out posterior disease [19].

By correctly identifying your subtype and monitoring it through examinations and imaging tests, your care team can tailor your medications to manage the inflammation [1][15].

Common questions in this guide

What are the main types of scleritis?
Scleritis can affect the front of the eye, called anterior scleritis, or the back, called posterior scleritis. Anterior disease may be diffuse, nodular, or necrotizing, and these patterns help doctors judge severity and choose treatment.
What does necrotizing scleritis mean?
Necrotizing scleritis is a severe form in which areas of blood flow stop, causing tissue death and rapid thinning of the sclera. A related form called scleromalacia perforans can cause marked thinning with little pain or redness and is often associated with long-standing rheumatoid arthritis.
How is posterior scleritis found if it cannot be seen from the outside?
Doctors often use B-scan ultrasound to look for fluid in the space around the eye and changes around the optic nerve. A T-shaped pattern can support the diagnosis, but it is not required, so a missing T-sign does not rule out posterior scleritis.
Which imaging tests can evaluate scleritis?
AS-OCT measures the thickness of the sclera and can show fluid within the eye wall. UBM provides a detailed view of the front of the eye, while B-scan ultrasound is especially useful for looking for posterior scleritis.
Can scleritis be linked to autoimmune disease or infection?
Noninfectious scleritis involves an immune response that damages the sclera, and some forms are associated with autoimmune disease such as long-standing rheumatoid arthritis. Because infection can also be relevant, your doctor may evaluate for bacterial, fungal, or viral causes before starting treatment.
Can scleritis cause vision changes without obvious eye redness?
Yes. Posterior scleritis may cause deep pain or vision loss while the inflammation is hidden behind the eye, so obvious redness may be absent.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Given my scleritis, what specific autoimmune diseases are we screening for, and which lab tests have been ordered?
  2. 2.How will the clinical examination and imaging guide my long-term treatment plan?
  3. 3.Is there any evidence of 'avascular' areas or 'necrosis' that could threaten the structural integrity of my eye?
  4. 4.Have we considered an infection (bacterial, fungal, or viral) before starting my treatment?
  5. 5.How will we use imaging to monitor if my treatment is working?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (19)
  1. 1

    Current Approach for the Diagnosis and Management of Noninfective Scleritis.

    Dutta Majumder P, Agrawal R, McCluskey P, Biswas J

    Asia-Pacific journal of ophthalmology (Philadelphia, Pa.) 2020; (10(2)):212-223 doi:10.1097/APO.0000000000000341.

    PMID: 33290287
  2. 2

    Immunopathological Analysis of a Mouse Model of Arthritis-Associated Scleritis and Implications for Molecular Targeted Therapy for Severe Scleritis.

    Nishio Y, Taniguchi H, Takeda A, Hori J

    International journal of molecular sciences 2021; (23(1)) doi:10.3390/ijms23010341.

    PMID: 35008766
  3. 3

    Current insights in the pathogenesis of scleritis.

    Vergouwen DPC, Rothova A, Berge JCT, et al.

    Experimental eye research 2020; (197()):108078 doi:10.1016/j.exer.2020.108078.

    PMID: 32504648
  4. 4

    Ocular Pharmacology for Scleritis: Review of Treatment and a Practical Perspective.

    Stem MS, Todorich B, Faia LJ

    Journal of ocular pharmacology and therapeutics : the official journal of the Association for Ocular Pharmacology and Therapeutics 2017; (33(4)):240-246 doi:10.1089/jop.2016.0127.

    PMID: 28355124
  5. 5

    [Scleritis and systemic diseases: What should know the internist?]

    Bielefeld P, Saadoun D, Héron E, et al.

    La Revue de medecine interne 2018; (39(9)):711-720 doi:10.1016/j.revmed.2018.02.001.

    PMID: 29496270
  6. 6

    Morphological features in anterior scleral inflammation using swept-source optical coherence tomography with multiple B-scan averaging.

    Kuroda Y, Uji A, Morooka S, et al.

    The British journal of ophthalmology 2017; (101(4)):411-417 doi:10.1136/bjophthalmol-2016-308561.

    PMID: 27388252
  7. 7

    Clinical profile of patients with anterior nodular scleritis in India.

    Patnaik G, Sudharshan S, George AE, et al.

    Indian journal of ophthalmology 2020; (68(9)):1925-1928 doi:10.4103/ijo.IJO_2154_19.

    PMID: 32823416
  8. 8

    [Diagnosis and treatment approach for necrotizing scleritis (NS): A clinical case].

    Hernández-Camarena JC, Rodríguez-García A, Valdez-García J

    Gaceta medica de Mexico 2015; (151(4)):525-8.

    PMID: 26290030
  9. 9

    Necrotizing Scleritis: A Review.

    Dutta Majumder P, Agarwal S, Shah M, et al.

    Ocular immunology and inflammation 2024; (32(7)):1405-1419 doi:10.1080/09273948.2023.2206898.

    PMID: 37279404
  10. 10

    Clinical spectrum and management of anterior scleritis: case reports.

    Ördögh D, Smeller L, Szabó DJ, Sohár N

    Therapeutic advances in ophthalmology 2025; (17()):25158414251356374 doi:10.1177/25158414251356374.

    PMID: 40823648
  11. 11

    Monocular posterior scleritis presenting as acute conjunctivitis: A case report.

    Li YZ, Qin XH, Lu JM, Wang YP

    World journal of clinical cases 2020; (8(20)):5030-5035 doi:10.12998/wjcc.v8.i20.5030.

    PMID: 33195678
  12. 12

    Clinical features and visual outcomes of scleritis patients presented to tertiary care eye centers in Saudi Arabia.

    Al Barqi M, Behrens A, Alfawaz AM

    International journal of ophthalmology 2015; (8(6)):1215-9 doi:10.3980/j.issn.2222-3959.2015.06.25.

    PMID: 26682176
  13. 13

    Optical coherence tomography in the diagnosis of scleritis and episcleritis.

    Shoughy SS, Jaroudi MO, Kozak I, Tabbara KF

    American journal of ophthalmology 2015; (159(6)):1045-1049.e1.

    PMID: 25771347
  14. 14

    Optical coherence tomography versus ophthalmic examination findings in the management of anterior scleritis: A prospective study.

    BenAbderrahim K

    Journal francais d'ophtalmologie 2022; (45(1)):40-46 doi:10.1016/j.jfo.2021.07.009.

    PMID: 34823890
  15. 15

    Anterior segment spectral domain optical coherence tomography imaging of patients with anterior scleritis.

    Levison AL, Lowder CY, Baynes KM, et al.

    International ophthalmology 2016; (36(4)):499-508 doi:10.1007/s10792-015-0153-8.

    PMID: 26597942
  16. 16

    High-resolution ultrasound biomicroscopy as an adjunctive diagnostic tool for anterior scleral inflammatory disease.

    Zur D, Neudorfer M, Shulman S, et al.

    Acta ophthalmologica 2016; (94(6)):e384-9 doi:10.1111/aos.12995.

    PMID: 26892270
  17. 17

    The clinical features of posterior scleritis with serous retinal detachment: a retrospective clinical analysis.

    Dong ZZ, Gan YF, Zhang YN, et al.

    International journal of ophthalmology 2019; (12(7)):1151-1157 doi:10.18240/ijo.2019.07.16.

    PMID: 31341807
  18. 18

    Clinical Features, Treatment, and Visual Outcomes of Posterior Scleritis from Tertiary Eye Care Center.

    Tellioğlu A, Yargı Özkoçak B, Kemer Atik B, et al.

    Ocular immunology and inflammation 2024; (32(7)):1323-1329 doi:10.1080/09273948.2023.2241556.

    PMID: 37549312
  19. 19

    A Rare Case of Posterior Scleritis Masquerading as Acute Angle Closure Glaucoma: Highlighting the Diagnostic Value of Multimodal Imaging.

    Asteris P, Bagli E, Kalogeropoulos C

    Cureus 2025; (17(6)):e85282 doi:10.7759/cureus.85282.

    PMID: 40612831

This page explains scleritis subtypes and imaging for educational purposes and does not replace medical advice. An ophthalmologist should interpret your examination and scans and guide treatment for your specific situation.

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