Download MBBS Ophthalmology PPT 2 Episcleritis And Scleritis Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 2 Episcleritis And Scleritis Lecture Notes

Episcleritis and Scleritis


Applied Anatomy

Sclera forms the posterior five-

sixth opaque part of the of the


Its whole outer surface is covered

by Tenon's capsule and bulbar


Its inner surface lies in contact

with choroid with a potential

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

optic nerve pass.

Microscopic structure
1. Episcleral tissue.
2. Sclera proper.
3. Lamina fusca.
1. Conjunctival vessels
2. Episcleral vessels
3. Deep vascular plexus

Benign recurrent inflammation of the episclera,
Never progresses to scleritis
Rarely associated with systemic disease

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

endogenous tubercular or streptococcal toxins.

Histologically, there occurs localised lymphocytic infiltration

of episcleral tissue associated with oedema and congestion of

overlying Tenon's capsule and conjunctiva.

Clinical picture
Redness, mild ocular discomfort, burning sensation or

foreign body sensation.

Rarely, mild photophobia and lacrimation may occur.

Simple or diffuse episcleritis
? Sectoral redness
? Diffuse redness
? Resolves in 1-2 weeks
Nodular episcleritis
? Focal, raised, nodular
? Sclera uninvolved
? Longer to resolve
Vessels remain radial and mobile
Palpation of the globe often elicits marked tenderness in

scleritis, but generally not in episcleritis.

Phenylephrine diagnostic test:
Hyperemia usually blanches with topical phenylephrine

(2.5%) in episcleritis but not in scleritis.

Mild cases
? Usually no specific Rx
? If discomfort
? Lubricant
? Topical NSAID eg acular (keterolac trimethamine)
? Mild topical corticosteroid
Or systemic Ibuproven/aspirin
Investigate in recurrent cases.

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

a comparatively serious disease which may cause visual impairment

and even loss of the eye if treated inadequately.

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

Clinical classification of Scleritis
It can be classified as follows:
I. Anterior scleritis (98%)
1. Non-necrotizing scleritis (85%)
(a) Diffuse
(b) Nodular
2. Necrotizing scleritis (13%)
(a) with inflammation
(b) without inflammation (scleromalacia perforans)
II. Posterior scleritis (2%)
Associated systemic conditions

qRheumatoid Arthritis
1:200 develop scleritis

q Connective Tissue Disease
Wegener granulomatosis
Systemic lupus erythematosus
Polyarteritis nodosa
Ankylosing spondilytis

Associated systemic conditions

qHerpes Zoster Ophthalmicus
qMetabolic disorders like gout and thyrotoxicosis
qGranulomatous diseases like
? Tuberculosis,
? Syphilis,
? Sarcoidosis,
? Leprosy
q Miscellaneous
Surgically induced

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

Clinical features

1. Non-necrotizing anterior diffuse


Commonest variety,
Widespread inflammation involving a

quadrant or more of the anterior sclera.

The involved area is raised and salmon

pink to purple in colour

Clinical features

2. Necrotizing anterior nodular


characterised by one or two hard, purplish

elevated scleral nodules, usually situated

near the limbus

Sometimes, the nodules are arranged in a

ring around the limbus (annular


Clinical features

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

transparent and ectatic with uveal tissue shining through it.

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

(scleromalacia perforans).

? 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
? Proptosis
? Restricted ocular movements
? Disc or macular edema
? Choroidal folds or detachment
? Uveal effusion syndrome
? Retinal detachment
? Scleral thickening seen on CT or USG B scan.

1. TLC, DLC and ESR
2. Serum levels of complement (C3), immune complexes,

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

immunological survey.

3. FTA - ABS, VDRL for syphilis.
4. Serum uric acid for gout.
5. Urine analysis.
6. Mantoux test.
7. X-rays of chest, paranasal sinuses, sacroiliac joint and orbit

to rule out foreign body especially in patients with nodular

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


Subconjunctival steroids are contraindicated because they

may lead to scleral thinning and perforation

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

of the eye with incarceration of the uveal tissue.

Due to weakening of the eye wall resulting from any

degenerative or inflammatory condition of the same.

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)

A: Intercalary staphyloma

B. Ciliary staphyloma

Equatorial staphyloma

Posterior staphyloma

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

cornal ulcer.

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

This post was last modified on 07 April 2022