it is all about conjunctiva and sclera anatomy and clincical coocrelaltions . hope it will be beeneficial

2. Conjunctiva ,Episclera ,Sclera :-
Anatomy , Nerve supply, Vascular
supply & Clinical correlations
Moderator:- Presenters :-
Mr. Sanjeeb Kumar Mishra Bipin koirala
Jenisha bhattarai
MMC , IOM

3.  Presentation layout:-
1. Embryology
 Conjunctiva
 sclera
2. Anatomy
3. Vascular supply
4. Nerve supply
5. Applied anatomy.
6. Summary
7. References

4.  Embryology
Conjunctiva:-
 Develops from the ectoderm lining the lids and
covering the globe.
 Conjunctival glands develop as a growth of the basal
cells of upper conjunctival fornix. Fewer glands develop
from the lower fornix.

5.  Embryology
Sclera:-
 Sclera is developed from the mesenchymal cells
surrounding the optic cup.
 The developmental process starts at limbal equatorial
region around seventh week of gestation and is
completed by fifth months.
 Deposition of elastin and GAGs are added to
extracellular matrix at a later date.

6.  Conjunctiva:-
Translucent mucous membrane lining the
posterior surface of eyelids and anterior
surface of eye.
Stretches from lid margin to limbus with
conjunctival sac in between.

7. Conjunctiva
Palpebral
Marginal
Tarsal
Orbital
Bulbar
Limbal
Scleral
Conjunctival
Fornix
Superior
Inferior
Lateral
Medial
 Parts of conjunctiva:-

8.  Palpebral Conjunctiva:-
 Extends from lid margin to 2 mm on the back of the lid
upto a shallow groove called sulcus subtarsalis.
 Common site for lodgment of conjunctival foreign body.
 It is actually a transitional zone between skin and
the conjunctiva proper.
1. Marginal conjunctiva:-

9. 2. Tarsal conjunctiva:-
Thin , transparent & highly vascular.
Upper tarsal firmly adherent to whole
tarsal plate.
Lower tarsal adherent only to half width
of tarsus.
Tarsal conjunctiva is commonest site
of follicular and papillary rxn.

10. 3.Orbital conjunctiva:-
Lies between tarsal conjunctiva and
fornix.
Orbital conjunctiva of upper lid lies
over Muller's muscle.

11.  Seperated from anterior
sclera by Episcleral tissue
and tenon’s capsule.
 Separated from anterior sclera by Episcleral
tissue and Tenon’s capsule
 Only tissue in body where vessels are visible
 It has two parts:-
1.Scleral conjunctiva
 Bulbar conjunctiva:-
2.Limbal conjunctiva
 3 mm ridge of bulbar conjunctiva
around cornea
 The conjunctiva, tenon’s capsule
and the Episcleral tissue are
fused

12.  Conjunctival fornix:-
Continuous circular cul-de sac broken only on medial side by
caruncle and plica semilunaris.
Joins bulbar conjunctiva with palpebral conjunctiva.
Broken on its medial site by caruncle and the plica semilunaris.
Can be subdivided into Superior , Inferior , Medial & Lateral
fornixes.

13.  Extends from upper border of the tarsal
plate to 10mm above the upper limbus,
reaches superior orbital margin.
 Superiorly attached to the fascial sheath
of the Levator muscle and superior rectus
muscles.
 Foreign body in superior fornix-double
eversion.
1. Superior fornix

14.  Extension - lower border of the lower
tarsal plate to 8mm from the lower
limbus.
 located near the inferior orbital margin.
 Attached to extension of fascial sheath
of the inferior rectus and the inferior
oblique muscle.
2.Inferior fornix

15.  Extends behind the equator of the eyeball.
 14 mm from the lateral limbus.
 5mm from the lateral canthus.
3. Lateral fornix
4. Medial fornix
 Shallow cul-de-sac
 Caruncle and plica semilunaris
lies here in the pool of tears
called lacus lacrimalis.

16.  Figure showing dimension of various parts in
conjunctiva

17.  Crescentic fold of conjunctiva present
in medial canthus.
 Vestigial structure.
 Represents nictitating membrane of
lower animals.
 Plica semilunaris

18.  Small, pinkish mass in inner canthus
medial to Plica semilunaris
 Piece of modified skin & has sweat
glands, sebaceous glands & hair
follicles
Caruncle

19. Degenerative conditions of conjunctiva.
 Pinguecula.
1. Yellowish-white patch on the bulbar conjunctiva.
2. Age related change.
3. Commonly seen in individual exposed to UV light,
dust &wind.
4. Elastotic degeneration in substantia propria a/w
deposition of hyaline materials.

20. Continue..
5. Bilateral and stationery condition with
triangular patch near limbus.
6. Apex lies away from cornea.
7. Complications like abscess formation
inflammation and conversion into
pterygium is also seen.
Pingueculitis

21.  Pterygium
1. Wing shaped fold seen to be encroaching cornea.
2. Seen in individual with prolonged exposure to UV
dry heat, dust and wind.
3. Degenerative and hyperplastic condition of conjunctiva.
4. Elastotic degeneration destroying corneal epithelia bowman’s
layers & superficial stroma.
5. Apex lies towards cornea and frequently seen in nasal side .

22. Continue…
6. Pterygium can be divided into 4 parts :-
a. Head b. Neck c. Body d. Cap
7. Depending upon progression 2 types.
a. Progressive b. Regressive
How to
differentiate
true with
pseudo
pterygium???
What is
double
pterygium??

23. Concretions.
1. Formed due accumulation of inspissated mucus
& epithelial debris .
2. Degenerative condition seen in elderly individual.
3. Seen in palpebral conjunctiva ( Upper>>Lower).
4. Yellowish- white & Hard looking .
5. Can cause FB sensation and excess lacrimation .

24.  Conjunctivochalasis
 Seen as fold of redundant conjunctiva b/w
globe & lower lid protruding over lid margin.
 Normal ageing change but exacerbated by
stress , inflamn, dry eye.
 Produces excess lacrimation due to blockage to
L. Punctum and interference to lower tear
meniscus.

25. Histology of conjunctiva:-
It consists of 3 layers as follows:-
1. Epithelium
2. Adenoid layer
3. Fibrous layer

26.  Epithelium
Epithelium varies from region to region.
1.Marginal conjunctiva:-
Five layered non keratinized stratified
squamous epithelium.
 Superficial:- Squamous cells
 Intermediate:- Polyhedral cells
 Deepest:- Cylindrical cells

27. 2. Tarsal conjunctiva:-
Two layered epithelium.
Upper eyelid:-
 Superficial layer:- Cylindrical cells
 Deep layer:- Cuboidal cells
Lower eyelid:-
3 to 4 layers of cells from deep to superficial.
 Cubical cells
 Polygonal cells
 Elongated wedge shaped cells
 Cone shaped cells

28. 3. Fornix and bulbar conjunctiva:-
 3 layered epithelium.
 Superficial layer: cylindrical cells
 Middle layer: Polyhedral cells
 Deep layers: cuboidal cells
4. Limbal conjunctiva:-
 8 to 10 stratified squamous epithelium.
 Contains palisades of vogt.
 Epithelium of palisade zone provide germinative
zone for the corneal epithelium.

29. 2. Adenoid Layer:-
 Fine connective tissue reticulum containing
lymphocytes.
 Most developed in fornixes.
 Develops at 2 to 3 months of life.
Conjunctival inflammation in an infant doesn’t
produces follicular rxn.

30. 3. Fibrous layer:-
 Network of collagenous and elastic fibers.
 Contains nerves and blood vessels.
 Thicker than adenoid layer.
 Thin at tarsal conjunctiva.

31.  Conjunctival glands
On the basis of types of secretion, conjunctival glands can be divided
into:-
Glands
associated with
conjunctiva
Mucin Glands
Goblet Cells
Henle’s Gland
Glands of
Manz
Accessory
Glands
Gland of
Krause
Gland of
Wolfring

32. Mucin glands
a) Goblet cells:-
 Unicellular mucous glands.
 Present in conjunctiva except marginal
mucocutaneous junction and limbal conjunctiva.
 Formed from basal layer of conjunctiva and
migrate towards the surface.
 Cells destroyed after discharging their content.
 Density high in children than in young adults.

33. b) Henle’s glands:-
 Not true glands.
 Tubular structures containing few goblet cells.
 Present in palpebral conjunctiva.
c) Glands of manz:-
 Found in limbal conjunctiva.
 Its presence is controversial in human.

34.  Functions of mucin:-
 Mucin lubricate and protects the epithelial
cells.
 Maintains tear film stability by lowering
surface tension.
Clinical importance:-
 Destruction of goblet cells occurs in
Epithelium xerosis.
 No. of goblet cells is increased in
inflammatory conditions.

35.  Accessory glands:-
A. Glands of Krause:-
 Lies deep in sub conjunctival tissue.
 Upper fornix- 42
 Lower fornix - 6 to 8
B. Glands of wolfring:-
 Upperboarder of superior tarsus - 2 to 5
 Lower boarder of inferior tarsus - 2

36.  Blood supply of conjunctiva:-
 Blood supply of conjunctiva is facilitated by:-
1. Marginal Arcade of eyelid
2. Peripheral Arcade of eyelid
3. Anterior Cilliary arteries

37. Perforating branches from peripheral
arterial arcade
Pierce the Levator palpebral muscle
Ascending Branch
Continue as posterior
conjunctival arteries
Reach conjunctiva & divides
Descending Branches
Marginal Branches Tarsal Branches
Reach conjunctiva & divides
Pierce the tarsus at the sulcus subtarsalis
Perforating branches from marginal arterial arcade
Anastomosis

38. Pass upwards & bend
round the superior
fornix to ascend under
the bulbar conjunctiva
Posterior conjunctival
arteries
Ascending Branch of
peripheral tarsal arcade
Travel along the tendon of
the superior fornix to
ascend under the bulbar
conjunctiva
Anterior conjunctival
arteries
Anterior ciliary
arteries
Send branches to
the pericorneal
plexus

39. Venous drainage
Veins from
conjunctiva
Venous plexus of eyelid
Superior/inferior
ophthalmic veins
A circumcorneal zone of veins
5-6mm from the limbus
Anterior ciliary
veins
 Venous drainage:

40.  Lymphatic drainage:-
From
medial side
From lateral
side
Submandibular
lymph node
Preauricular
lymphnode

41.  Nerve supply to conjunctiva:-
1. Bulbous conjunctiva
Anterior two third of circum corneal
limbus is supplied by long cilliary
nerves.
2. Superior palpebral conjunctiva,
superior fornix, superior peripheral
one third of bulbous conjunctiva is
supplied by trochlear, supra orbital,
lacrimal and frontal nerve.

42. 3. Inferior lateral fornix, inferior lateral
conjunctiva and inferior lateral one third
of bulbous conjunctiva is supplied by
lacrimal nerve.
4. Inferior medial fornix, inferior medial
conjunctiva, inferior medial one third of
bulbous conjunctiva is supplied by
Infra orbital nerve.

43. Symptomatic conditions of conjunctiva
 Hyperemia of conjunctiva.
 Chemosis of conjunctiva.
 Ecchymosis of conjunctiva.
 Xerosis of conjunctiva.
 Discoloration of conjunctiva

44.  Hyperaemia of conjunctiva
 It is due to congestion of conjunctival blood vessels.
 Etiologically two types:-
Acute hyperaemia Chronic hyperaemia
Caused by temporary
irritants.
Like FB, concretions,
dust, smoke, fumes,
rubbing with hands ,
extreme hot or cold.
Chronic alcoholics ,
smokers, residents of dusty
area and ill ventilated
rooms , pts suffering from
rosacea , insomnia.

45. Contd…..
 Pts complains discomfort, grittiness, tiredness etc.
 Can be treated by removal of causes.
 Decongestants can be used for symptomatic relief

46.  Chemosis of conjunctiva
 A.K.A edema of conjunctiva.
 Causes of Chemosis can be grouped as:-
Local inflammatory
conditions
Local blood / lymph
flow obstructions
Systemic causes
1.Conjunctivitis,
2.Corneal ulcers,
3.Uveitis
4.Acute meibomitis,
5.Orbital cellulitis,
6.Dacryoadenitis,
7.Dacryocystitis
1. Acute congestive
glaucoma
2. Orbital
lymphatics
blockage
3. Cavernous sinus
thrombosis
4. Orbital tumors &
pseudo tumors.
1. Anaemia
2. Hypoproteinemia
3. Congestive heart
failure etc..

47.  Ecchymosis of conjunctiva
 A.K.A Subconjunctival hemorrhage.
 Etiology
a. Trauma or during surgery
b. Acute hemorrhagic conjunctivitis.
c. Whooping cough , violent compression of thorax.
d. HTN & DM
e. Bleeding disorders

48.  Xerosis of conjunctiva
 Condition in which conjunctiva becomes dry & lusterless.
 2 types (Etiologically)
Parenchymatous Xerosis Epithelial Xerosis
 Occurs due to cicatrical
disorganization of
conjunctiva.
 Seen in trachoma, SJS,
thermal & chemical burns
 Conditions causing
conjunctival exposure like
ectropion, proptosis,
lagophthalmos.
 Occurs due to
hypovitamintosis A.
 Typically seen in children's
 Conjunctiva is seen
wrinkled, thickened and
pigmented.

49.  Discoloration of conjunctiva.
 Normal conjunctiva is transparent and looks pinkish too.
 Conjunctiva discoloration is seen in various systemic conditions.
Red Yellow Blue Greyish Brown
 Sub
conjunctival
Hemorrhage
 Jaundice
 Malaria
 Yellow fever
 Conjunctival
fat in elderly
 A/w blue
sclera
 Scleromalacia
perforans
 Application
of kajal
 Non
melanocytic
pigmentation
 Melanocytic
pigmentation

50. Conjunctivitis:-
 Inflammation of conjunctiva.
 Symptoms of conjunctivitis.
 lacrimation
 Burning sensation
 Itching
 Pain (mild)
 Photophobia
 FB sensation & Grittiness

51. Be careful!!!!
Some symptoms seen during
conjunctivitis might also be seen in
other ocular pathologies like as
anterior uveitis , acute congestive
glaucoma
So conjunctivitis must be
differentiated from
anterior uveitis and
acute congestive
glaucoma before starting
treatment

52. Tabular comparison b/w Acute conjunctivitis, Acute congestive glaucoma
& Acute iridocyclitis
Features Acute
conjunctivitis
Acute
iridocyclitis
Acute congestive
glaucoma
Onset Gradual Usually gradual Sudden
Pain Mild Moderate Severe
Discharge Mucopurulent Watery Watery
Colored haloes May be present Absent Present
Vision Normal slightly impaired Markedly impaired
Congestion Superficial Deep ciliary Deep ciliary
Pupil Normal Small, irregular Large ,oval
Media Clear Hazy Hazy
Ant. chamber Normal May be deep shallow
Iris Normal Muddy Oedematous
IOP Normal Normal Usually raised

53. Clinical signs in conjunctivitis.
Congestion/ Hyperemia :-
Dilation of superficial blood vessels.

54.  Clinical pictures in different types of congestion.
Conjunctival
congestion
Circum ciliary
congestion
Mixed congestion

55. Discharge
Consists of exudates filtered from the conjunctival
epithelium through dilated blood vessels.
Types of discharges
Nature of discharge Associated conjunctivitis
Watery Allergic & Acute viral
Mucoid Chronic allergic
Mucopurulent Chlamydial & Acute bacterial
Mod purulent Acute bacterial
Severe purulent Gonococcal conjunctivitis

56.  Follicles
Translucent boiled grain like raised structure.
 Upper tarsal conjunctiva & at fornixes.
 Histology :-
1. Formed by scattered aggregation of
lymphocytes in adenoid layer.
2. Central part composed immature lymphocytes
& peripherally matured lymphocytes.
3. Blood vessels are present around and across the
lesions.
In case of trachoma follicles are
seen in bulbar conjunctiva Herbert
follicles

57.  Papillae
 Hyperplasia of conjunctival epithelium is seen.
 Seen in palpebral conjunctiva and at limbus.
 Histology:-
1. Composed of stromal infiltration with inflammatory cells.
2. Central core is composed of dilated blood vessels.
 Based on size:-
1. Micro papillae
2. Macro papillae (<1mm)
3. Giant papillae (>1mm)

58. Difference between Papillae & Follicles.
Features Papillae Follicles
Commonly
seen
Bacterial & Allergic
conjunctivitis
Viral and chlamydial
conjunctivitis
Appearance Reddish and velvety Translucent & boiled grain.
Blood vessels Dilated blood vessels form
center core of papillae
Passes around & across the
follicle
Composition Hyperplastic epithelium Hyperplastic lymphoid tissue
Where are
they found??
Palpebral conjunctiva and
limbal areas
Fornixes and palpebral
conjunctiva

59.  Membranes:-
True membrane Pseudo membrane
Involves inflammatory exudates
interdigitated with superficial layer
inflamed conjunctival epithelium.
Involves coagulated exudates
adherent to inflamed epithelium
Removal leads to tearing and
bleeding.
Can be peeled away easily leaving
underlying epithelium intact without
bleeding.
Neisseria gonorrhea,
Corynebacterium diphtheria ,
SJS
EKC, ALLERGIC conjunctivitis, Severe
bacterial conjunctivitis

60. Clinical figures of True VS Pseudo membranes
TRUE MEMBRANE PSEUDO MEMBRANE

61.  Conjunctival scarring:-
 Whitish irregular, linear or stellate shaped
opaque patches seen on tarsal conjunctiva.
 Scarring is A/w loss of goblet cells and accessory
lacrimal glands.
 Seen in Trachoma, atopic conjunctivitis.
Cicatricial pemphigoid etc.
What is Arlt’s
line??

62.  Conjunctival infiltration:-
 It represents cellular recruitment to the site of
chronic inflammation.
 Typically accompanies papillary response.
 Details of normal tarsal conjunctival blood vessels
is lost.

63.  Chemosis:-
 A.k.A conjunctival oedema.
 Translucent swelling of conjunctiva.
 Chemosis is seen in chronic allergic conjunctivitis.
 Also seen in severe infective conjunctivitis.

64.  Haemorrhage:-
 Seen in both viral as well as bacterial conjunctivitis
 In Viral haemorrhages are multiple, small &
discrete.
 Picorna virus commonly cause haemorrhagic
conjunctivitis.
 In Bacterial conjunctivitis haemorrhages are large
and diffused.
 Pneumococcus bacteria commonly causes SCH.

65.  lymphadenopathy
 A.K.A lymphadenitis ( Enlargement of lymph nodes.)
 Commonly seen conjunctivitis A/W viral infections.
 Also seen in chlamydial & severe bacterial
conjunctivitis.
 Common in Gonococcal conjunctivitis.
 Preauricular lymph node is commonest to be
affected.

66. Classification of
conjunctivitis..

67.  Based on Etiology
(a) Infective
conjunctivitis
Bacterial conjunctivitis
Viral conjunctivitis
Chlamydial conjunctivitis
Ophthalmia neonatrum
Granulomatous conjunctivitis

68. (b) Allergic
conjunctivitis
Simplex allergic conjunctivitis
Vernal keratoconjunctivitis
Atopic keratoconjunctivitis
Giant papillary conjunctivitis
Phlyctenular conjunctivitis
Contact dermoconjunctivitis

69. (c) Cicatricial
conjunctivitis
Ocular mucous membrane
pemphigoid
Stevens Johnson syndrome
Toxic epidermal necrolysis
Secondary cicatricial
conjunctivitis
(d) Toxic
conjunctivitis

70. Secondary conjunctivitis:-
 Conjunctivitis associated with disorders of lacrimal
apparatus , eyelid deformities is called secondary
conjunctivitis.
 Some of the associated conditions are :-
Dacryocystitis
Trichiasis
Entropion
Ectropion
Facial palsy

71. Differentiating conjunctivitis based on clinical features:-
Clinical features Bacterial Viral Allergic Chlamydial
Congestion Marked Moderate Mild to mod. Moderate
Chemosis ++ + ++ +/-
SCH +/- +/- - -
Discharge Purulent or
Mucopurulent
Watery Ropy/watery Mucopurulent
Papillae +/- - ++ +/-
Follicles - + - ++
Pseudo membrane +/- +/- - -
Pannus - - -(except VKC) +
Lymphadenopathy + ++ - +/-

72.  Cysts of conjunctiva
Congenital
cystic lesion
Lymphatic cysts
Retention cyst
Traumatic cyst
Epithelial
down growth
cyst
Aqueous cyst
Pigmented
epithelial cyst
Parasitic cyst

73.  Conjunctival tumors
 They can be both pigmented as well as non pigmented.
 On the basis of nature and tissue of origin their types are:-
Tissue of origin Benign Malignant
Epithelial Papilloma Squamosal cell carcinoma
Glandular Adenoma Adenocarcinoma
Connective tissue Fibroma Sarcoma
Vascular Hemangioma Angiosarcoma
Reticular system Lymphoid hyperplasia Lymphosarcoam
Pigment cells Naevus Melanoma

74.  Dermoid
 Congenital tumors
 Occurring at limbus as solid white mass.
 Has sebaceous gland , hair , collagenous
connective tissue.
 Lined by epidermoid.

75.  Lipodermoid
 Congenital tumor.
 Found at limbus or outer canthus.
 Appears soft, white , moveable, sub
conjunctival mass.
Orbital fat prolapse

76.  Naevi
 A.k.A congenital moles of conjunctiva.
 Greyish, blackish or brownish coloration.
 Found as a flat or slightly raised nodule in
bulbar conjunctiva.
 May show increase size during puberty &
pregnancy.
 Pigmentary change seen during
inflammation.

77. Anatomy of sclera:-
 Dense connective tissue composed of collagen
bundles of varying diameter.
 Whole outer surface is covered by Tenon’s capsule.
 Anterior part is covered by bulbar conjunctiva.

78. Sclera contd..
Inner surface of sclera lies in contact
with choroid with a potential supra
choroidal space between.
Sclera forms the posterior 5/6th part
of globe.
Opaque appearance: less uniform
orientation of collagen fibres.

79. Thickness of sclera.
 Differs from individual to individual also based
upon age.
 Thinner in children than adult & female than
male.
 Sclera is thickest posteriorly and gradually gets
thin anteriorly.
 Posterior thickness is (1mm)
 Thinnest at insertion of EOMS (0.3mm)
 At equator (0.4-0.8mm)
 At limbus (0.8 mm)

80.  Special regions of sclera:-
1. Scleral sulcus
 It is a furrow on inner surface of ant most point of
sclera.
 It houses schlemn’s canal.
2. Scleral spur
 Circular rim in ant most part of sclera lying deep to
schlemn’s canal.
 Meridonial fibers of ciliary body are attached to it.

81. Special region contd..
3. Lamina cribrosa
 Sieve like sclera
 Optic nerve passes through it.
 During glaucoma in which IOP will rise
lamina cribrosa will gradually
increase in posterior curvature.

82. Microscopic structures:-
Histologically sclera consists of following layers:-
1. Episcleral tissue
2. Sclera proper
3. Lamina fusca

83. 1. Episcleral tissue
 It is thin, dense vascularized layer of connective tissue which covers sclera
proper.
 Fine fibroblasts, macrophages and lymphocytes are also present in this layer.
2. Sclera proper
 It is an avascular structure which consists of dense bundles of
collagen fibers.
 The band of collagen tissue cross each other in all direction.
3. Lamina fusca
 It is the innermost part of sclera which blends with supra choroidal and
supracilliary lamina of the uveal tract.
 It is brownish in color due to presence of pigmented cells.

84.  Vascular Supply:-
 It is relatively avascular structure.
 Anterior cilliary artery form a dense
Episcleral plexus anterior to the
insertion of rectus muscle.
 Long and short posterior cillary artery
supplies the posterior part.

85.  Nerve Supply:-
Sclera is supplied by branches from the long cilliary nerves
which pierce it 2 to 4 mm from limbus to form a plexus.
Anterior region is supplied by long ciliary nerve
Posterior region is also supplied by short ciliary nerve.

86.  Apertures piercing sclera:-
Sclera is pierced by three sets of apertures:-
1. Posterior apertures :-
 These are situated around the optic nerve and transmit long and short
cilliary nerves and vessels.
2. Middle apertures:-
 These are four in numbers.
 Are situated slightly posterior to equator through which the
four vortex veins(venae verticosae passes)

87. Apertures contd...
3. Anterior Apertures:-
 Are situated 3 to 4mm away
from the limbus.
 Anterior cilliary vessels passes
through the apertures.

88.  Inflammation of sclera.
 Can be classified into Episcleritis & Scleritis.
Episcleritis Normal sclera Scleritis

89.  Episcleritis
Benign and recurrent inflammation of Episclera & Tenon's capsule.
Causes of episcleritis:-
1. Idiopathic
2. Gout & connective tissue
disorders
3. H/S Rxn like staphylococcal
toxins
4. Herpes zoster , syphillis , TB
Symptoms:-
1. Redness
2. Mild ocular discomfort
3. Burning ,FB sensation
4. Rarely photophobia and
watering.

90. Episcleritis contd..
Clinically two types :-
Simple Episcleritis Nodular episcleritis
Characterized by sectoral ( occasionally
diffused) inflamn of episclera.
Characterized by pink flat nodule
surrounded by blood vessels injection.

91.  Scleritis
 Chronic inflammation of scleral proper.
 Serious than episcleritis as it can severely affect vision.
Causes :-
1. Idiopathic
2. RA, PAN, SLE.
3. Gout, Thyrotoxicosis.
4. HZO , Staphylococcal &
streptococcal infection.
5. Syphilis, leprosy
Symptoms:-
1. Pain
2. Redness
3. Photophobia
4. Diminution of vision

92. Scleritis contd..
85%
13% 2%
Scleritis classification
Non necrotising scleritis Necrotising scleritis posterior scleritis

93.  Differentiating Scleritis from Episcleritis.
 It is very important to differentiate Episcleritis from
Scleritis.
 In gross appearance both may look similar.
 But their proper differentiation is necessary during clinical
practice because scleritis may be vision threatening.

94.  Blanching:-
 Helps to differentiate Scleritis from Episcleritis.
 Vasoconstrictors are used for this process.
 Phenylephrine (0.125%) are commonly used.
 A drop is instilled in red eye and observed for 10-15 minutes.
 If redness disappears then Episcleritis but if redness still persist then Scleritis.

95.  Slit lamp examination.
1. Using optical section ( slit beam).
2. Using red free filter ( green filter).
 Will give more contrast to subtle red blood vessels.
 Making easier in viewing dominant area of vascular congestion
and zone of avascularity.
Episcleritis Scleritis
 Anterior slit beam is bowed forward
due Episcleral edema.
 Posterior beam is flat against normal
sclera.
 In scleritis posterior beam also bows
forward due to underlying Scleral
edema.

96.  Blue sclera
 Marked generalized bluish
discoloration of sclera.
 Due to scleral thinning.
 Seen in conditions like as:-
Osteogenesis
imperfecta
Marfan’s
syndrome
Bupthalmos
High myopia

97. What is the scleral color of newly born baby??
Bluish tint is seen in sclera of newly
born.
In newly born sclera is translucent and bluish
tint is due to underlying uveal tissue
coloration.

98.  Sclerocornea
 Congenital anomaly
 Sclera blends with cornea
 No clear cut boundary b/w sclera & cornea.
 Opacity ranges from peripheral to total.

99.  Staphyloma:-
 Localized outward bulging of weak & thin
outer tunic eyeball( sclera and cornea).
 Lined by uveal tissue and shines through
fibrous coat.
 Anatomically can be divided into
followings:-
Staphyloma
Anterior staphyloma
Intercalary staphyloma
Ciliary staphyloma
Equatorial staphyloma
Posterior staphyloma

100.  Clinical pictures in different types of staphylomas.
Anterior
staphyloma
Intercalary
staphyloma
Ciliary
staphyloma
Equatorial
staphyloma
Posterior
staphyloma

101.  Scleromalacia.
Degenerative thinning of sclera.
 Commonly seen in anterior necrotizing
scleritis (scleromalacia perforans).
 Patients with Rheumatoid arthritis
commonly present with this condition.

102.  Summary:-
 Conjunctiva, Tenon’s capsule, episclera and sclera are respectively present
ongoing from outer layer to inner layer forming protective coating.
 Conjunctivitis must be differentiated from anterior uveitis and acute
congestive glaucoma before starting treatment.
 It is very important to differentiate Episcleritis from Scleritis. Proper
differentiation is necessary during clinical practice because scleritis may be
vision threatening.

103.  References:-