Episcleritis and Scleritis
Ophthalmology
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Applied AnatomySclera 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 bulbarconjunctiva.
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 theinsertion 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 plexusEPISCLERITIS
Benign recurrent inflammation of the episclera,
Common
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BenignSelf-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/aspirinInvestigate 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 episcleritisUsually bilateral
More common in females
Associated with connective tissue disorders in upto 50% of cases.
Granulomatous inflammation
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Mild to blinding spectrumClinical 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 scleritisq Connective Tissue Disease
Wegener granulomatosis
Systemic lupus erythematosus
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Polyarteritis nodosaAnkylosing spondilytis
Associated systemic conditions
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qHerpes Zoster OphthalmicusqMetabolic 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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qIdiopathicClinical 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 colourClinical features
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Signs2. Necrotizing anterior nodular
scleritis.
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characterised by one or two hard, purplishelevated 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 orbitto 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 taperedslowly.
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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STAPHYLOMASEctasia 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 anydegenerative 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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ManagementTreat the underlying cause like, scleritis, RA, vit A def or
cornal ulcer.
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Local excision and patch graft of cornea or scleraEnucleation with implant.
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