Download MBBS Ophthalmology PPT 2 Episcleritis And Scleritis Lecture Notes

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Applied Anatomy

Sclera forms the posterior five-

sixth opaque part of the of the

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eyeball.

Its whole outer surface is covered

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by Tenon's capsule and bulbar

conjunctiva.

Its inner surface lies in contact

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with choroid with a potential

suprachoroidal space in between.
It is generally thinner in children & females.

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Sclera is thickest posteriorly (1mm) and is thinnest at the

insertion of extraocular muscles (0.3 mm).

Lamina cribrosa is a sieve-like sclera from which fibres of

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optic nerve pass.

Microscopic structure
1. Episcleral tissue.

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2. Sclera proper.
3. Lamina fusca.
Vasculature:
1. Conjunctival vessels
2. Episcleral vessels

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3. Deep vascular plexus
EPISCLERITIS

Benign recurrent inflammation of the episclera,
Common

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Benign
Self-limiting
Recurrent
Never progresses to scleritis
Rarely associated with systemic disease

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Etiology
Exact etiology is not known.
It is found in association with gout, rosacea and psoriasis.
It has also been considered a hypersensitivity reaction to

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endogenous tubercular or streptococcal toxins.

Pathology
Histologically, there occurs localised lymphocytic infiltration

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of episcleral tissue associated with oedema and congestion of

overlying Tenon's capsule and conjunctiva.

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Clinical picture
Symptoms.
Redness, mild ocular discomfort, burning sensation or

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foreign body sensation.

Rarely, mild photophobia and lacrimation may occur.

Signs

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Simple or diffuse episcleritis
? Sectoral redness
? Diffuse redness
? Resolves in 1-2 weeks
Nodular episcleritis

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? Focal, raised, nodular
? Sclera uninvolved
? Longer to resolve
Vessels remain radial and mobile
Palpation of the globe often elicits marked tenderness in

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scleritis, but generally not in episcleritis.

Phenylephrine diagnostic test:
Hyperemia usually blanches with topical phenylephrine

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(2.5%) in episcleritis but not in scleritis.

Management
Mild cases

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? Usually no specific Rx
? If discomfort
? Lubricant
? Topical NSAID eg acular (keterolac trimethamine)
? Mild topical corticosteroid

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Or systemic Ibuproven/aspirin
Investigate in recurrent cases.
SCLERITIS

Scleritis refers to a chronic inflammation of the sclera proper. It is

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a comparatively serious disease which may cause visual impairment

and even loss of the eye if treated inadequately.

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Relatively rarer than episcleritis
Usually bilateral
More common in females
Associated with connective tissue disorders in upto 50% of cases.
Granulomatous inflammation

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Mild to blinding spectrum

Clinical classification of Scleritis
It can be classified as follows:
I. Anterior scleritis (98%)

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1. Non-necrotizing scleritis (85%)
(a) Diffuse
(b) Nodular
2. Necrotizing scleritis (13%)
(a) with inflammation

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(b) without inflammation (scleromalacia perforans)
II. Posterior scleritis (2%)
Associated systemic conditions

qRheumatoid Arthritis

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1:200 develop scleritis

q Connective Tissue Disease
Wegener granulomatosis
Systemic lupus erythematosus

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Polyarteritis nodosa
Ankylosing spondilytis

Associated systemic conditions

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qHerpes Zoster Ophthalmicus
qMetabolic disorders like gout and thyrotoxicosis
qGranulomatous diseases like
? Tuberculosis,
? Syphilis,

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? Sarcoidosis,
? Leprosy
q Miscellaneous
Surgically induced
Infectious

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qIdiopathic


Clinical features
Symptoms

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? Pain
? Redness
? Photophobia
? Lacrimation
? Diminution of vision

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Clinical features

Signs
1. Non-necrotizing anterior diffuse

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scleritis.

Commonest variety,
Widespread inflammation involving a

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quadrant or more of the anterior sclera.

The involved area is raised and salmon

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pink to purple in colour


Clinical features

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Signs
2. Necrotizing anterior nodular

scleritis.

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characterised by one or two hard, purplish

elevated scleral nodules, usually situated

near the limbus

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Sometimes, the nodules are arranged in a

ring around the limbus (annular

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scleritis).

Clinical features

Signs

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3. Necrotizing scleritis with inflammation.
The affected necrosed area is thinned out and sclera becomes

transparent and ectatic with uveal tissue shining through it.

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It is usually associated with anterior uveitis.
4. Anterior necrotizing scleritis without inflammation

(scleromalacia perforans).

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? Usually associated with seropositive RA
? Painless scleral thinning due to ischaemia.
Posterior Scleritis
? Defined as primarily arising posterior to the equator
? Painful or painless diminution of vision

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? Proptosis
? Restricted ocular movements
? Disc or macular edema
? Choroidal folds or detachment
? Uveal effusion syndrome

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? Retinal detachment
? Scleral thickening seen on CT or USG B scan.

Investigation
1. TLC, DLC and ESR

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2. Serum levels of complement (C3), immune complexes,

rheumatoid factor, antinuclear antibodies and L.E cells for an

immunological survey.

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3. FTA - ABS, VDRL for syphilis.
4. Serum uric acid for gout.
5. Urine analysis.
6. Mantoux test.

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7. X-rays of chest, paranasal sinuses, sacroiliac joint and orbit

to rule out foreign body especially in patients with nodular

scleritis.

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Management
(A) Non-necrotising scleritis.
Steroid eye drops and systemic indomethacin 100 mg
daily for a day and then 75 mg daily.
B) Necrotising scleritis. It is treated by topical

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steroids and heavy doses of oral steroids tapered
slowly.
Immuno-suppressive agents like methotrexate or cyclophos-

phamide.

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Subconjunctival steroids are contraindicated because they

may lead to scleral thinning and perforation

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STAPHYLOMAS
Ectasia or bulging of the outer coats (cornea, sclera or both)

of the eye with incarceration of the uveal tissue.

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Due to weakening of the eye wall resulting from any

degenerative or inflammatory condition of the same.

Types:

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A. Anterior (involves cornea)
B. Intercalary (with in 2mm of limbus)
C. Ciliary (2-8mm behind the limbus
D. Equatorial (14mm behind the limbus)
E. Posterior (posterior to equator)

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A: Intercalary staphyloma

B. Ciliary staphyloma

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Equatorial staphyloma

Posterior staphyloma

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Management
Treat the underlying cause like, scleritis, RA, vit A def or

cornal ulcer.

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Local excision and patch graft of cornea or sclera
Enucleation with implant.
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