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PubMed This is a summary of 18 peer-reviewed journal articles Updated
Ophthalmology

Diagnostic Exams, Imaging, and Lab Reports

At a Glance

Scleromalacia perforans is often painless, so doctors use slit-lamp exams, photographs, and AS-OCT to assess thinning of the eye wall. Blood tests and TB or syphilis screening help identify associated disease and make immune-suppressing treatment safer.

Because scleromalacia perforans (SP) is often “quiet” and painless, doctors cannot rely on your symptoms to track the disease. Instead, they use a combination of high-tech imaging and detailed blood work to look beneath the surface. These tests are designed to answer three critical questions: How thin is the eye wall? Is an underlying disease associated with the damage? And is it safe to start powerful immune-suppressing medications? [1][2]

The Eye Exam: Beyond the Naked Eye

A standard eye exam for SP begins with a slit-lamp examination. Your doctor uses this specialized microscope to look for specific structural warning signs:

  • Avascular Plaques: These are “dead zones” in the eye wall where blood vessels have disappeared. These white, bloodless patches often precede the “melting” of the tissue [1][3].
  • Scleral Thinning and Ectasia: The doctor will look for areas where the white part of the eye is so thin that the dark inner layer (the uvea) is visible, or where the eye wall is bulging outward (ectasia) [4][3].
  • Slit-lamp Photography: Doctors often take high-resolution digital photos of your eye. These photos act as a “baseline” to compare against future visits, making it easier to spot even tiny changes in the size or color of the thinned areas [1][5].

Mapping the Melt: Anterior-Segment OCT (AS-OCT)

One of the tools for managing SP is Anterior-Segment OCT. This is a non-contact imaging test that uses light waves to create a cross-sectional map of the front of your eye [6].

  • Measuring Thickness: AS-OCT allows your doctor to evaluate the thickness of your sclera. While it can be a useful adjunct, device capability limits interpretation, and there is no universally validated threshold that predicts perforation [7].
  • Detecting “Hidden” Melting: Sometimes, AS-OCT can show structural changes indicating subclinical tissue abnormalities before they are obvious on the surface [6][8].
  • Long-term Monitoring: AS-OCT is one part of serial clinical examination—alongside photos and visual acuity—to help track the disease over time [8].

The “Scleritis Workup”: Your Lab Tests

Because SP is so frequently linked to systemic autoimmune diseases, a “scleritis workup” is often tailored to your history and examination. Your doctor may order a panel of blood tests to check for markers of inflammation and specific antibodies:

  • Rheumatoid Factor (RF) and anti-CCP: These tests support a diagnosis of Rheumatoid Arthritis. However, it is important to know that these levels do not reliably measure ocular activity [2][9].
  • ANCA (PR3 and MPO): These tests look for vasculitis (blood vessel inflammation). A positive ANCA requires clinical correlation, often including urinalysis and renal function, rather than diagnosing vasculitis by itself [10][2].
  • ESR and CRP: These are markers of general inflammation. They can be completely normal in active localized disease, or elevated for unrelated reasons [10][2].

Why Infectious Screening is Important

Before starting treatments that “turn off” part of your immune system, your doctor must consider infectious causes. Suppressing the immune system in a patient with an undiagnosed infection can cause the infection to spread rapidly [11][12].

  • Tuberculosis (TB) Testing: Usually done via a skin test (Mantoux) or a blood test (QuantiFERON). TB can “hide” in the body for years and flare up during immunosuppression [13][14].
  • Syphilis Serology: Syphilis is known as “the great imitator” because it can look exactly like autoimmune scleritis. If syphilis is the cause, the treatment is antibiotics [15][16].
  • Cultures or Biopsy: If your eye has discharge, abscesses, or isn’t responding to standard treatment, your doctor may take a tiny sample (biopsy) or “scraping” to test for bacteria or fungi [17][18].

Common questions in this guide

What can a slit-lamp exam reveal in scleromalacia perforans?
A slit-lamp exam uses a specialized microscope to look for blood-vessel-free plaques, areas where the sclera is thin enough to show darker tissue underneath, and outward bulging of the eye wall. Your doctor may also take photographs to compare changes over time.
What does AS-OCT show in scleromalacia perforans?
AS-OCT is a non-contact scan that uses light waves to make a cross-sectional image of the front of the eye. It can help estimate scleral thickness and identify hidden structural changes, but no universally validated thickness cutoff can predict perforation.
Can blood tests show whether scleromalacia perforans is active?
Tests such as ESR and CRP measure general inflammation, while RF and anti-CCP help support a rheumatoid arthritis diagnosis and do not reliably measure eye activity. These results can be normal or elevated for reasons unrelated to the eye, so your doctor interprets them with the examination and your history.
What does a positive ANCA test mean if I have scleromalacia perforans?
A positive ANCA can raise concern for vasculitis, but it does not diagnose vasculitis by itself. Your clinician may correlate it with symptoms and check urine and kidney function, and sometimes other organs such as the lungs.
Why are TB and syphilis tests done before immune-suppressing treatment?
Immune-suppressing medicines can allow an unrecognized infection to spread, so doctors screen for infections before starting them. TB may remain hidden and reactivate, while syphilis can resemble autoimmune scleritis and requires antibiotic treatment if it is the cause.
How often will I need repeat eye imaging?
The schedule is individualized based on your eye examination, photographs, vision testing, and disease course. Repeat AS-OCT may be used as part of ongoing monitoring for structural changes that are not yet visible or noticeable.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What did my slit-lamp exam show regarding 'avascular plaques' or areas of the eye without blood flow?
  2. 2.Can we review my AS-OCT images so I can see exactly how much scleral thickness I have left?
  3. 3.Are my RF and anti-CCP levels being monitored to see if my rheumatoid arthritis is the driver for this eye change?
  4. 4.Since I'm starting immunosuppression, have we confirmed my TB and syphilis status to ensure these treatments are safe?
  5. 5.My ANCA test was positive—does this mean we need to check my kidneys or lungs for signs of vasculitis?
  6. 6.How often will we repeat the AS-OCT imaging to check for 'subclinical' melting that I can't see or feel?

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 (18)
  1. 1

    Monitoring therapy in anterior necrotizing scleritis with inflammation with anterior segment optical coherence tomography.

    Vidal Oliver L, López Montero A, Gil Hernández I, et al.

    European journal of ophthalmology 2021; 11206721211065564 doi:10.1177/11206721211065564.

    PMID: 34866457
  2. 2

    Scleritis and associated systemic diseases: contribution of systemic examination, follow-up, and additional investigations.

    Soubrier M, Vasseneix C, Jacquot R, et al.

    Journal of ophthalmic inflammation and infection 2025; (16(1)):7 doi:10.1186/s12348-025-00566-7.

    PMID: 41447412
  3. 3

    Sclerokeratitis and Secondary Glaucoma in Relapsing Polychondritis in a 30-Year-Old Asian Male Patient: A Case Report.

    Flores LKC, Siazon RR

    Cureus 2025; (17(2)):e79128 doi:10.7759/cureus.79128.

    PMID: 40109806
  4. 4

    Spontaneous Descemet Membrane Detachment After Necrotizing Scleritis: A Case Report.

    Margulies KS, Kiavash V, Syed ZA

    Cornea 2026; (45(2)):239-242 doi:10.1097/ICO.0000000000003930.

    PMID: 40600595
  5. 5

    Semilunar sign of cornea: A multimodal analysis of the posterior corneal opacity in non-infectious anterior scleritis.

    Kumar DA, Agarwal A, Chandrasekar R, Chinnappan RM

    Indian journal of ophthalmology 2022; (70(4)):1197-1202 doi:10.4103/ijo.IJO_2073_21.

    PMID: 35326015
  6. 6

    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
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    Case Report: Subconjunctival Triamcinolone Acetate-associated Scleral Necrosis: Is It Really Obsolete?

    Agarwal R, Bafna RK, Chetan C, Sharma N

    Optometry and vision science : official publication of the American Academy of Optometry 2021; (98(9)):1016-1020 doi:10.1097/OPX.0000000000001761.

    PMID: 34433205
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    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
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    Case of isolated scleromalacia perforans with seropositivity for rheumatoid arthritis.

    Hajizadeh S, O'Donnell C, Dore A

    BMJ case reports 2024; (17(6)) doi:10.1136/bcr-2024-259863.

    PMID: 38925670
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    ANCA-associated scleritis: impact of ANCA on presentation, response to therapy and outcome.

    Perray L, Nguyen Y, Clavel Refregiers G, et al.

    Rheumatology (Oxford, England) 2024; (63(2)):329-337 doi:10.1093/rheumatology/kead252.

    PMID: 37233203
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    Chronic necrotizing sclerouveitis caused by Alternaria doliconidium.

    Menean M, Nicolini N, Cimino L, et al.

    European journal of ophthalmology 2026; (36(1)):NP16-NP18 doi:10.1177/11206721251369539.

    PMID: 40956900
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    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
  13. 13

    Antineutrophil cytoplasmic antibody-positive scleritis: Clinical profile of patients from a tuberculosis-endemic region.

    Majumder PD, Sudharshan S, George AE, et al.

    Indian journal of ophthalmology 2018; (66(11)):1587-1591 doi:10.4103/ijo.IJO_777_18.

    PMID: 30355867
  14. 14

    Clinical Features of Scleritis Across the Asia-Pacific Region.

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    Ocular immunology and inflammation 2019; (27(6)):920-926 doi:10.1080/09273948.2018.1484496.

    PMID: 29953309
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    Syphilitic scleritis and episcleritis: A review.

    Shields MK, Furtado JM, Lake SR, Smith JR

    Asia-Pacific journal of ophthalmology (Philadelphia, Pa.) 2024; (13(3)):100073 doi:10.1016/j.apjo.2024.100073.

    PMID: 38795870
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    [Scleritis and systemic diseases: What should know the internist?]

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    PMID: 29496270
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    Infectious Scleritis: Pathophysiology, Diagnosis, and Management.

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    Eye & contact lens 2021; (47(8)):434-441 doi:10.1097/ICL.0000000000000813.

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    Infectious Scleritis Masquerading as Isolated Orbital Cellulitis: A Case Report.

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This page explains diagnostic exams, imaging, and laboratory screening for scleromalacia perforans for informational purposes only and does not constitute medical advice. Your ophthalmologist and other specialists should interpret your results and decide whether treatment is safe.

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