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ANATOMY
HISTOLOGY
Lamina
Sclera: fusca
Melanocytes
5/6 posterior SCLERA
White opaque Loose episcleral
Insertion of extra ocular CT
proper
muscle
3 layers:
Episclera
Stroma
Lamina fuscha
stroma
EPISCLERA
• Outermost layer ……nutrition to sclera
– PRESENTATION
Unilateral redness
Mild discomfort/ tenderness
Watering
Photophobia….may be present
– SIGNS:
SIMPLE EPISCLERITIS:
–Commonest type
–Sectoral /diffuse redness
–Resolves spontaneously in 1-2
weeks
EPISCLERITIS
NODULAR EPISCLERITIS:
Conjunctivitis
Scleritis
EPISCLERITIS
TREATMENT:
– Not always required
– Reassurance / cold compressions
– Simple lubricants
– Topical steroids
May lead to recurrence
Frequent intense instillation on short term pulse
based
– Oral NSAIDs :
Flurbiprofen 100 mg t.i.d
SCLERITIS
It is characterized by edema and
cellular infiltration of the entire
thickness of sclera.
Much less common than episcleritis
Older age group
Trivial……….sight threatening
condition
Causes of Scleritis
Causes and associations :50% of cases
1.Autoimmune diseases
Ankylosing spondylitis.
Rheumatoid arthritis
Wegner’s granulomatosis.
Systemic lupus erythematosis.
Psoriatic arthritis.
Ulcerative colitis
2.Granulomatous diseases
T.B
Syphilis
Sarcoidosis
Leprosy
Causes of Scleritis
SURGICALLY INDUCED.
INFECTIOUS SCLERITIS:
– Spread of infection from corneal
ulcer
– Trauma
– Excision of a pterygium or adjunctive
B irradiation or mitomycin C
– Causative agents:
Pseudomonas aeruginosa
Strep. Pneumoniae
Stap. Aureus
Varicella zoster virus
SCLERITIS
INFECTIOUS SCLERITIS:
SIGNS:
– A. DIFFUSE SCLERITIS:
Relatively benign condition
Wide spread inflammation
Involves a sector or entire sclera
Characteristic distortion of normal radial
vascular pattern
ANTERIOR NON-NECROTIZING
SCLERITIS
NODULAR SCLERITIS:
PRESENTATION:
Combined therapy:
I/V methyl prednisolone 500-1000 mg + cyclophosphamide
500mg
ANTERIOR NECROTIZING SCLERITIS
WITHOUT INFLAMMATION
Also known as scleromalacia perforans
In women with long standing rheumatoid arthritis
Usually bilateral
SIGNS:
– Asymptomatic yellow necrotic patches in uninflammed sclera
– Enlargement ,spread and coalescence
– Progressive exposure of underlying uvea as a result of scleral
thinning
– Staphyloma formation may occur
– Spontaneous perforation is rare unless IOP is raised
TREATMNENT is ineffective
POSTERIOR SCLERITIS
Uncommon, often misdiagnosed
Affects women twice as often as men 1/3
rd patients are under 40 yrs of age at
presentation
Patients over 50 yrs: at inc. risk of harbouring
systemic disease and suffering visual loss 2/3
rd cases have unilateral involvement
Guarded visual prognosis
Visual impairment to some degree in 1/3 rd
cases
POSTERIOR SCLERITIS
PRESENTATION:
– Variable
– Depends upon exact site of involvement
– Most common symptoms are pain and visual impairment
SIGNS :
– EXTERNAL :
Lid oedema and fullness
Proptosis and ophthalmoplegia
Associated ant. Scleritis in 1/3 rd cases
POSTERIOR SCLERITIS
INTERNAL :
– Disc swelling
– Macular oedema
– Choroidal folds
– Exudative retinal detachment
– Ring choroidal detachment
– Subretinal lipid exudation
POSTERIOR SCLERITIS
INVESTIGATIONS:
– ULTRASONOGRAPGHY:
Thickening of post sclera
Fluid in Tenon space – “T” sign
Stem of “T” is formed by optic n.
Cross bar by gap containing fluid in sub-Tenon
space
– CT SCAN:
Post scleral thickening
POSTERIOR SCLERITIS
USG / CT FINDINGS
Thickening of
posterior sclera
POSTERIOR SCLERITIS
DIFFERENTIAL DIAGNOSIS:
OPTIC NEURITIS
RHEGMATOGENOUS RD
CHOROIDAL TUMOUR
POSTERIOR SCLERITIS
TREATMENT:
– In elderly patients with associated systemic
disease, as for necrotizing anterior scleritis