ophthalmology ppt

1. Diseases of sclera

2. anatomy
• Sclera  posterior 5/6th opaque part of
the external fibrous tunic of the eyeball.

3. • outer surface }covered by Tenon's capsule.
• anterior part } covered by bulbar conjunctiva.

4. Its inner surface lies in contact with choroid
with a
potential suprachoroidal space in between

6. Thickness of sclera.
• thinner }children and in females Sclera
• thickest} posteriorly (1mm)
• gradually becomes thin when traced anteriorly.
• thinnest } insertion of extraocular muscles (0.3 mm).
• Lamina cribrosa is a sieve-like sclera from which fibres of optic nerve
pass.

7. Apertures of sclera
• Anterior
• Anterior ciliary vessels
• Middle
• four vortex veins (vena verticosae)
• Posterior
• Optic nerve
• Long & short ciliary nerves

8. Layers of sclera
sclera
episclera
Sclera proper
Lamina fusca
thin, dense vascularised
layer of connective tissue fibroblasts,
macrophages and
lymphocytes
avascular structure dense bundles of
collagen fibres.
innermost blends with suprachoroidal and
supraciliary
laminae of the uveal tract.
brownish in colour
presence of pigmented cells.

9. Inflammations of sclera
• Episcleritis (superficial)
• Scleritis(deep)

10. episcleritis
• benign recurrent inflammation of the episclera,
• involving the overlying Tenon's capsule
• but not the underlying sclera.

11. etiology
• Unknown
• Associated with gout/psoriasis/rosacea
• Hypersensitivity reaction to endogenous tubercular or streptococcal
toxins.

12. incidence
• M>f
• Young adults

13. pathology
• localised lymphocytic infiltration of episcleral tissue
•  oedema and congestion of overlying Tenon's capsule and
conjunctiva.

14. symptoms
• by redness,
• mild ocular discomfort described as gritty, burning or
• foreign body sensation

15. signs
• diffuse episcleritis,
• whole eye maybe involved to
some extent,
• the maximum inflammation is
confined to one or two
quadrants
• nodular episcleritis,
• a pink or purple flat nodule
surrounded by injection is seen,
2-3 mm away from the limbus
• The nodule is firm, tender and
the overlying conjunctiva moves
freely.

16. Clinical course
• limited course of 10 days to 3 weeks =resolves spontaneously.
• recurrences common and tend to occur in bouts.
• a fleeting type of disease (episcleritis periodica) may occur

17. DD
• Inflammed pinguecula
• Scleritis
• Fb reaction on bulbar conjunctiva

18. treatment
• 1.Topical corticosteroid eyedrops 2-3 hourly,
• 2. Cold compresses applied to the closed lids
• 3. Systemic non-steroidal anti-inflammatory drugs
• flurbiprofen (300 mg OD),
• indomethacin (25 mg three times a day), or
• oxyphenbutazone

19. scleritis

20. scleritis
• c/c inflmn of sclera proper
• F>m
• Elderly

21. etiology
• Autoimmune collagen disorders RA(common),Wegener's
granulomatosis,PAN, SLE and ankylosing spondylitis.
• Metabolic disorders gout & thyrotoxicosis
• Infections herpes zoster ophthalmicus, c/c staphylococcal and
streptococcal infection
• Granulomatous diseases tb,syphilis, sarcoidosis, leprosy
• Miscellaneous conditions irradiation, chemical burns, Vogt-Koyanagi-
Harada syndrome, Behcet's disease and rosacea
• Surgically induced scleritis ocular surgery. within 6 month postoperatively.
• Idiopathic

22. pathology
• infiltration by PMNL , lymphocytes, plasma cells and macrophages
• Fibrinoid necrosis, destruction of collagen
•
• granuloma surrounded by multinucleated epitheloid giant cells

23. classification
• 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%)

24. Symptoms
• moderate to severe pain
• deep and boring in character and often
• wakes the patient early in the morning .
• radiates to the jaw and temple.
• localised or diffuse redness
• mild to severe photophobia
• lacrimation.

25. Signs
• 1. Non-necrotizing anterior diffuse scleritis.
• commonest,
• widespread inflammation involving a quadrant or more of the
anterior sclera.
• The area is raised and salmon pink to purple in colour

26. • Non-necrotizing anterior nodular scleritis.
• one or two hard, purplish elevated scleral nodules,
• usually situated near the limbus
• the nodules are arranged in a ring around the limbus (annular
scleritis).

27. • 3. Anterior necrotizing scleritis with inflammation.
• acute severe form of scleritis
• characterised by intense localised inflammation
• associated with areas of infarction due to vasculitis
• necrosed sclera thinned out (sclera becomes transparent and
ectatic) with uveal tissue shining through it.
• Anterior uveitis+

28. • Anterior necrotizing scleritis without inflammation (scleromalacia
perforans).
• elderly females with long-standing RA.
• yellowish patch of melting sclera (due to obliteration of arterial
supply);
• with overlying episclera andconjunctiva completely separates from
the surrounding normal sclera.
• Eventually absorbs leaving behind it a large punched out area of
• thin sclera through which the uveal tissue shines
• Spontaneous perforation rare

29. • posterior scleritis.
• the sclera behind the equator.
• frequently misdiagnosed.
• associated inflammation of adjacent structures,
• exudative retinal detachment,
• macular oedema,
• proptosis and
• limitation of ocular movements.

30. complications
• 2’ glaucoma (due to uveitis…)
• Complicated cataract
• sclerosing keratitis,
• keratolysis

31. investigations
• 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 scleritis.

32. Treatment
• (A) Non-necrotising scleritis
• Topical steroid eyedrops and
• systemic indomethacin 100 mg daily for a day and then 75 mg daily until
inflammation resolves.
• (B) Necrotising scleritis.
• Topical steroids & heavy doses of oral steroids tapered slowly.
• In non-responsive cases, immuno-suppressive agents like methotrexate or
cyclophos-phamide
• Subconjunctival steroids are contraindicated because they may lead to scleral
thinning and perforation

33. Blue sclera

34. Blue sclera
• asymptomatic condition
• marked, generalised blue discolouration of sclera due to thinning.
osteogenesis imperfecta.
Marfan's syndrome,
Ehlers-Danlos syndrome,
pseudoxanthoma elasticum,
 buphthalmos,
High myopia and
 healed scleritis.

35. staphylomas

36. staphylomas
• localised bulging of weak and thin outer tunic of the eyeball (cornea
or sclera),
• lined by uveal tissue which shines through the thinned out fibrous
coat.

37. classification
• Anterior
• Intercalary
• Ciliary
• Equatorial
• posterior

38. Anterior staphyloma
• Ass. With ectasia of cornea & iris
• Due to perforating corneal ulcer & injury

39. Intercalary staphyloma
healing of a perforating injury or a peripheral corneal ulcer
to ectasia of weak scar tissue formed at the limbus
localised bulge in limbal area lined by root of iris

40. • marked corneal astigmatism Defective vision
• 2’angle closure glaucomaprogression of swelling
• Treatment
• localised staphylectomy under heavy doses of oral steroids.

41. Ciliary staphyloma
• bulge of weak sclera lined by ciliary body.
• about 2-3 mm away from the limbus
• thinning of sclera following perforating injury,
• scleritis and absolute glaucoma.
Ciliary staphyloma

42. Equatorial staphyloma
• bulge of sclera lined by the choroid in the equatorial region
• at the regions of sclera which are perforated by vortex veins.
• causes= scleritis and degeneration of sclera in pathological myopia

43. Posterior staphyloma
• bulge of weak sclera lined by the choroid behind the.
• common causes are pathological myopia, posterior scleritis and
perforating injuries.
• Diagnosis ophthalmoscopy.
• The area is excavated with retinal vessels dipping in it (just like
• marked cupping of optic disc in glaucoma)