SCLERITIS ,Causes , classification ,treatment ,Prognosis

1. Dr. MOHAMMAD SAQUIB
MBBS,MS
Consultant & HOD D/O OPHTHALMOLOGY
Fellow Dr Shroff charity ,Delhi .
Fellow HVDESAI ,PUNE
Ex-Registrar JNMCH,AMU
Founder Sec – www.medicsngo.org

2. SCLERITIS
A.Non- infectious
Anterior scleritis
• Diffuse
• Nodular
• Necrotizing- a) with inflammation
b)without inflammation
(scleromalacia perforans)

4. Applied anatomy of vascular coats
Scleritis
• Maximal congestion of
deep vascular plexus
• Slight congestion of
episcleral vessels
• Maximal congestion
of episcleral vessels
EpiscleritisNormal
• Radial superficial episcleral
vessels
• Deep vascular plexus
adjacent to sclera

6. Simple episcleritis
• Common, benign, self-limiting but frequently recurrent
• Typically affects young adults
Treatment
• Seldom associated with a systemic disorder
Simple sectorial episcleritis Simple diffuse episcleritis
• Topical steroids
• Systemic flurbiprofen ( 00 mg tid if unresponsive

8. Nodular episcleritis
• Less common than simple episcleritis
• May take longer to resolve
• Treatment - similar to simple episcleritis
Localized nodule which can be moved over sclera Deep scleral part of slit-beam
not displaced

11. Causes and Systemic Associations of Scleritis
1. Rheumatoid arthritis
• Wegener granulomatosis
• Polyteritis nodosa
• Systemic lupus erythematosus
2. Connective tissue disorders
3. Miscellaneous
• Relapsing polychondritis
• Herpes zoster ophthalmicus
• Surgically induced

12. Diffuse anterior scleritis
• Widespread scleral and episcleral injection
• Most common .Salmon pink –purple
• Relatively benign - does not progress to necrosis
• Oral steroids if unresponsive
Treatment
• Oral NSAIDs

13. Nodular anterior scleritis
Scleral nodule cannot be moved over
underlying tissue
Hard purplish elevated
More serious than diffuse scleritis
On cursory examination resembles
nodular episcleritis.
Situated near limbus
May arranged as ring i.e Annular
Scleritis
Treatment - similar to diffuse scleritis

16. Anterior necrotizing scleritis with inflammation
Progression
• Painful and most severe type, infarction due to vasculitis
• Complications - uveitis, keratitis, cataract and glaucoma
Treatment
• Oral steroids
• Immunosuppressive agents (cyclophosphamide, azathioprine, cyclosporin)
• Combined intravenous steroids and cyclophosphamide if unresponsive
• Scleral patch graft
Scleral necrosis and
visibility of uvea
Spread and coalescence
of necrosis
Avascular patches

18. • Asymptomatic and untreatable
• Yellowish patch of melting sclera, Dead white sclera with visible uvea
• Long standing scleritis
Progressive scleral thinning with exposure of underlying uvea
Anterior necrotizing scleritis without inflammation
(scleromalacia perforans)

19.  Scleral inflammation behind the equator
 Associated with inflammation of adjacent structures
 i.e-Exudative R.D ,Macular edema , Proptosis ,Restricted
ocular movement .

22.  5- 10 % of scleritis
 Clinically similar as non –infectious scleritis .
 Scleritis with purulent exudates .
 Formation of fistulae, painful nodule, conjuctival , scleral ulcers
 Complications: sclerosing keratitis , keratolysis , complicated cataract ,
secondary glaucoma
 Investigation
 A. TLC,DLC,ESR
 B.C3,IMMUNE COMPLEX, RA, ANTI NUCLEAR ANTIBODY
 C.FTA-ABS,VDRL SYPHILIS
 D.SERUM URIC ACID-GOUT
 E.URINE ANALYSIS
 F.MANTOUX
 G.X RAY CHEST
 Rx: Antimicrobial ,surgical debridement

23. Posterior scleritis
Signs
• About 20% of all cases of scleritis
• About 30% of patients have systemic disease
• Treatment similar to necrotizing scleritis with inflammation
Choroidal folds Subretinal exudation
Proptosis and
ophthalmoplegia
Disc swelling Exudative retinal
detachment
Ring choroidal
detachment

24. Imaging in posterior scleritis
Ultrasound
a - Thickening of posterior sclera
b -Fluid in Tenon space (‘T’ sign)
Axial CT
Posterior scleral thickening
a
b
a