Episcleritis and scleritis involve inflammation of the outer layers of the eye. Episcleritis affects just the episclera, while scleritis penetrates deeper into the sclera. Scleritis is more severe and can cause vision loss. It is often associated with autoimmune diseases. Treatment involves anti-inflammatory drugs like NSAIDs or corticosteroids. Necrotizing scleritis is the most severe form and requires prompt high-dose immunosuppressive therapy to prevent complications like scleral thinning and perforation that can cause permanent vision loss.

2. EPISCLERITIS/SCLERITIS

3. ANATOMY
• Episclera
• Scleral stroma
• Lamina fusca

4. EPISCLERA
• Outermost layer ……nutrition to sclera
• low friction surface
• Loose connective tissue
• Rich blood supply -> superficial n deep ant plexus
posterior episcleral plexus
• Superficial plexus n Conjunctival vessels mainly involved
in inflammation…..blanch with topical vasoconstictors

5. SCLERAL STROMA
• Dense fibrous tissue intermingled with elastic tissue
• Complete sphere of 22 mm diameter
• Irregularly arranged collagen fibers make it opaque n tough
• Visco elastic structure
• Biphasic response to deforming force
brief lengthening (elastic response)
slow stretching (viscid response)

6. LAMINA FUSCA
• Inner most layer
• Faintly brown due to melanocytes
• Separates it from external surface of choroid

7. BLOOD SUPPLY
• Sclera relatively avascular
structure
• Ant ciliary arteries form a
dense episcleral plexus ant to
insertions of recti muscles
• Long & short post ciliary
arteries supply posterior part
• Vessels don’t blanch with
vasoconstrictor

8. Nerve Supply
Ciliary nerves
• pierce sclera around optic nerve
• short ciliary nerves supply post. portion.
• two long posterior ciliary nerves supply ant.
region.

9. Functions of sclera
• Protection of intra ocular contents from trauma &
mechanical displacement.
• Preservation of shape of eye ball.
• Maintenance of exact position of different parts of optical
system
• Rigid insertion for extra ocular muscles

10. Ciliary flush / healing of surgical
incisions
• Scleral stroma has poor blood supply
• Episclera has rich blood supply from ant ciliary arteries
• Normally plexus is inconspicuous
• But in inflammation involving cornea, iris, ciliary body marked
vasodilatation may occur in limbal area, known as ciliary flush
• Rich blood supply  rapid healing of surgical wounds

11. Nerve supply of sclera / eye pain
• Profuse sensory innervation
• Inflammation causes dull aching pain
• Due to extra ocular muscles insertions into the
sclera, pain is made worse by ocular movement.

12. EPISCLERITIS
It is a common, benign self limiting and
frequently recurrent disorder which
typically affects young females
May be associated with underlying
disease(10%)
Can be divided into
– Simple
– Nodular

13. EPISCLERITIS
– PRESENTATION
Unilateral redness
Mild discomfort/ tenderness
Watering
Photophobia….may be present

14. – SIGNS:
SIMPLE EPISCLERITIS:
–Commonest type
–Sectoral /diffuse redness
–Resolves spontaneously in 1-2
weeks

17. EPISCLERITIS
NODULAR EPISCLERITIS:
– Localized ,raised ,congested nodule
– Takes longer time to resolve
Sclera not swollen
Sclera appears translucent

18. Nodular episcleritis

20. EPISCLERITIS
TREATMENT:
– Not always required
– Reassurance / cold compressions
– Simple lubricants
– Topical steroids
May lead to recurrence
Frequent intense instillation on short term pulse
based
– Oral NSAIDs :
Flurbiprofen 100 mg t.i.d

21. SCLERITIS
It is characterized by edema and
cellular infiltration of the entire
thickness of sclera.
Much less common than episcleritis
Older age group
Trivial……….sight threatening
condition

22. Causes of Scleritis
Causes and associations :50% of cases
1.Autoimmune diseases
Ankylosing spondylitis.
Rheumatoid arthritis
Wegner’s granulomatosis.
Systemic lupus erythematosis.
Psoriatic arthritis.
Ulcerative colitis
2.Granulomatous diseases
T.B
Syphilis
Sarcoidosis
Leprosy

23. Causes of Scleritis
SURGICALLY INDUCED.
INFECTIOUS SCLERITIS:
– Spread of infection from corneal ulcer
– Trauma
– Excision of a pterygium or adjunctive
B irradiation or mitomycin C
– Causative agents:
Pseudomonas aeruginosa
Strep. Pneumoniae
Stap. Aureus
Varicella zoster virus

24. SCLERITIS
INFECTIOUS SCLERITIS:
– Spread of infection from corneal ulcer
– Trauma
– Excision of a pterygium or adjunctive B
irradiation or mitomycin C
– Causative agents:
Pseudomonas aeruginosa
Strep. Pneumoniae
Stap. Aureus
Varicella zoster virus

25. SCLERITIS
Anatomical classification:
– Anterior scleritis (98%)
Non-necrotizing (85%) : diffuse or nodular
Necrotizing (13%) : with or without
inflammation
– Posterior scleritis (2%)

26. ANTERIOR NON-NECROTIZING
SCLERITIS
PRESENTATION:
– Similar to EPISCLERITIS
– More severe discomfort
SIGNS:
– A. DIFFUSE SCLERITIS:
Relatively benign condition
Wide spread inflammation
Involves a sector or entire sclera
Characteristic distortion of normal radial
vascular pattern

27. ANTERIOR NON-NECROTIZING
SCLERITIS
NODULAR SCLERITIS:
– High association with HZO
– Nodule can’t be moved over
underlying tissue
– Intermediate severity
– 25% cases having visual
impairment

28. ANTERIOR NON-NECROTIZING
SCLERITIS
TREATMENT:
– Oral NSAIDS : flurbiprofen 100 mg t.i.d
meloxicam 7.5 mg t.i.d
– Oral prednisolone : 40-80 mg daily
– Combined therapy
– Subconjunctival steroid injections:
Triamcinolone acetonide (40mg/ml)
Only for non-necrotizing type

29. ANTERIOR NECROTIZING
SCLERITIS WITH INFLAMMATION
Most severe and distressing form
Bilateral in 60%
Not necessarily simultaneous
There may be associated vascular
disease
Mortality rate of 25% within 5 yrs of
onset

30. ANTERIOR NECROTIZING
SCLERITIS WITH INFLAMMATION
PRESENTATION:
– Gradual onset of pain and localized redness
– Pain becomes severe and persistent and
radiates to temple ,brow or jaw
– Frequently interferes with sleep
– Responds poorly to analgesia

31. ANTERIOR NECROTIZING
SCLERITIS WITH INFLAMMATION
SIGNS:
Vaso-occlusive :
 Assosciated with RA
 Isolated patches of scleral edema with overlying
non perfused episclera and conjunctiva
 Patches coalesce….scleral necrosis
 Granulomatous:
 Associated with WG n PAN
 Start from limbus extend posteriorly
 Within 24 hr involve conjunctiva , episclera ,
sclera

33. ANTERIOR NON-NECROTIZING
SCLERITIS WITH INFLAMMATION
COMPLICATIONS:
– Staphyloma formation
– Scleral thinning…….Perforation
– Kerartitis: acute infiltrative,sclerosing,PUK
– Anterior uveitis:
Long standing uveitis may result into
– Sec. cataract
– Glaucoma
– Macular oedema
Poor prognosis
High incidence of visual impairment

34. ANTERIOR NECROTIZING
SCLERITIS WITH INFLAMMATIN
TREATMENT
– Oral prednisolone : 60-120 mg daily for 2-
3 days
– Immunosuppresive agents:
Cyclophosphamide
Azathioprine
Cyclosporin
Combined therapy:
I/V methyl prednisolone 500-1000 mg + cyclophosphamide
500mg

35. ANTERIOR NECROTIZING SCLERITIS
WITHOUT INFLAMMATION
Also known as scleromalacia perforans
In women with long standing rheumatoid arthritis
Usually bilateral
SIGNS:
– Asymptomatic yellow necrotic patches in uninflammed sclera
– Enlargement ,spread and coalescence
– Progressive exposure of underlying uvea as a result of scleral
thinning
– Staphyloma formation may occur
– Spontaneous perforation is rare unless IOP is raised
TREATMNENT is ineffective

37. POSTERIOR SCLERITIS
Uncommon, often misdiagnosed
Affects women twice as often as men
1/3 rd patients are under 40 yrs of age at
presentation
Patients over 50 yrs: at inc. risk of harbouring
systemic disease and suffering visual loss
2/3 rd cases have unilateral involvement
Guarded visual prognosis
Visual impairment to some degree in 1/3 rd
cases

38. POSTERIOR SCLERITIS
PRESENTATION:
– Variable
– Depends upon exact site of involvement
– Most common symptoms are pain and visual impairment
SIGNS :
– EXTERNAL :
Lid oedema and fullness
Proptosis and ophthalmoplegia
Associated ant. Scleritis in 1/3 rd cases

39. POSTERIOR SCLERITIS
INTERNAL :
– Disc swelling
– Macular oedema
– Choroidal folds
– Exudative retinal detachment
– Ring choroidal detachment
– Subretinal lipid exudation

40. POSTERIOR SCLERITIS
INVESTIGATIONS:
– ULTRASONOGRAPGHY:
Thickening of post sclera
Fluid in Tenon space – “T” sign
Stem of “T” is formed by optic n.
Cross bar by gap containing fluid in sub-Tenon
space
– CT SCAN:
Post scleral thickening

41. POSTERIOR SCLERITIS
USG / CT FINDINGS
Thickening of
posterior sclera

42. POSTERIOR SCLERITIS
DIFFERENTIAL DIAGNOSIS:
OPTIC NEURITIS
RHEGMATOGENOUS RD
CHOROIDAL TUMOUR

43. POSTERIOR SCLERITIS
TREATMENT:
– In elderly patients with associated systemic
disease, as for necrotizing anterior scleritis
– Young patients without associated systemic
disease usually respond well to NSAIDs