Anterior necrotizing scleritis with inflammation1.Presentation: Most severe form with gradual onset of pain and localized redness .2. Signs: a) Distortion or occlusion of blood vessels b) Development of scleral necrosis c) Gradual spread of necrosis around the globe d) Presence of associated anterior uveitis indicative of very severe disease involving ciliary bodyComplications: corneal involvement,cataract,glaucoma.
Anterior necrotizing scleritis with inflammation
Anterior necrotizing scleritis without inflammation1. Presentation: Asymptomatic2. Signs: Starts with a yellow necrotic patch Large areas of uvea become exposed3. Complications: Perforation rare unless IOP elevated
Posterior scleritis(cont…)• D/D: Optic neuritis Rhegmatogenous RD Choroidal tumour Orbital inflammatory disease or mass Uveal effusion syndrome Harada disease• USG: Thickening of posterior sclera with fluid in tenon space• CT: Thickening of posterior sclera with fluid in tenon space
Treatment• ANTERIOR NON-NECROTIZING SCLERITIS: Oral NSAIDS(flurbiprofen 100mg x tds) Oral prednisolone(40-80mg x od) Combination therapy of NSAIDS and lower dose steroids.• ANTERIOR NECROTIZING SCLERITIS WITH INFLAMMATION: Oral prednisolone(60-120mg x od tapered accordingly) Immunosuppressive agents Combined therapy with pulsed i.v methylprednsolone(500-1000mg) and cyclophosphamide(500mg)
Treatment(cont…)• ANTERIOR NECROTIZING SCLERITIS WITHOUT INFLAMMATION: No effective treatment• POSTERIOR SCLERITIS: a)Elderly patients with associated systemic disease are treated in the same way as those with anterior necrotizing scleritis. b)Young patients without associated systemic disease usually respond well to NSAIDS.
Surgical treatment• Extreme scleral thinning requires reinforcement.• Corneal marginal ulceration or keratolysis may require corneal grafting .
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