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Sclera
The sclera is the dense outer layer of the eyeball. It can develop two types of inflammation - episcleritis and scleritis. Episcleritis is more common and self-limiting, often affecting young adults, while scleritis is more severe and can be associated with underlying systemic diseases. Scleritis presents with redness and swelling of the sclera and is classified as anterior or posterior depending on location. Imaging like ultrasound and CT are useful for diagnosing posterior scleritis. Treatment involves topical or oral steroids, with immunosuppressants used for severe or resistant cases. Complications can include scleral thinning and staphylomas if left untreated.
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Sclera
- 1. Sclera Abdelmonem Hamed Professor ofOphthalmology Benha University
- 2. Special features ofSclera • Avascular • Dense fibrous tissue • Lack of reaction to insult • Two types of inflammation - episcleritis and scleritis
- 3. EPISCLERITIS AND SCLERITIS 1.Episcleritis • Simple • Nodular 2. Anterior scleritis • Non-necrotizing diffuse • Non-necrotizing nodular • Necrotizing with inflammation • Necrotizing without inflammation ( scleromalacia perforans ) 3. Posterior scleritis
- 4. Applied anatomy ofvascular 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
- 5. Simple episcleritis • Common,self-limiting, & recurrent • Typically affects young adults Treatment • Seldom associated with a systemic disorder Simple sectorial episcleritis Simple diffuse episcleritis • Topical steroids • Systemic Steroids if not responding to topical treatment
- 6. Nodular episcleritis • Lesscommon than simple episcleritis • May take longer to resolve • Treatment - similar to simple episcleritis Localized nodule which can be moved over sclera
- 7. Causes 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
- 8. Diffuse anterior non-necrotizingscleritis • Widespread scleral and episcleral injection • Relatively benign - does not progress to necrosis • Oral steroids if unresponsive Treatment • Oral NSAIDs
- 9. Nodular anterior non-necrotizingscleritis Scleral nodule cannot be moved over underlying tissue More serious than diffuse scleritis On examination resembles nodular episcleritis Treatment - similar to diffuse non-necrotizing scleritis
- 10. Anterior necrotizing scleritiswith inflammation Progression • Painful and most severe type • Complications - uveitis, keratitis, cataract and glaucoma Treatment • Oral steroids • Immunosuppressive agents (cyclosporin) • Combined intravenous steroids and cyclophosphamide if unresponsive Scleral necrosis and visibility of uvea Spread and coalescence of necrosis Avascular patches
- 11. • Asymptomatic anduntreatable • Associated with rheumatoid arthritis Progressive scleral thinning with exposure of underlying uvea Anterior necrotizing scleritis with inflammation (sclerokeratitis)
- 12. Anterior necrotizing scleritis: withoutinflammation (Scleromalacia perforans) Asymptomatic Mainly in females with longstanding RhA Large areas of uvea eventually exposed Spontaneous perforation rare No effective treatment
- 13. Posterior scleritis Signs • About20% of all cases of scleritis • About 30% of patients have systemic disease Choroidal folds Subretinal exudation Proptosis and ophthalmoplegia Disc swelling Exudative retinal detachment Ring choroidal detachment • Decreased vision • With or without pain
- 14. Differential Diagnoses 1. AllergicConjunctivitis 2. Atopic Keratoconjunctivitis 3. Bacterial Conjunctivitis 4. Bacterial Keratitis 5. Epidemic Keratoconjunctivitis 6. Fungal Keratitis 7. Giant Papillary Conjunctivitis 8. Acute Angle-Closure Glaucoma 9. Herpes Simplex Virus Keratitis 10. Interstitial Keratitis 11. Keratoconjunctivitis Sicca 12. Superior Limbic Keratoconjunctivitis 13. Toxoplasmosis 14. Viral Conjunctivitis
- 15. Imaging in posteriorscleritis Ultrasound a - Thickening of posterior scler (flat tire sign) b -Fluid in Tenon space (‘T’ sign) Axial CT Posterior scleral thickening a b a
- 16. Treatment of necrotizingscleritis Oral prednisone 1mg/kg/day Or Pulsed IV Methylprednisolone (solu-medrol 1 gm) Monitor pain in first 2-3 days Taper dose of steroids to response Immunosuppressives cyclosporine in steroid resistant cases Young people systemic NSAI.
- 17. Staphyloma • Staphyloma isa clinical condition characterised by an ectasia of the outer coats (cornea,or sclera or both) with an incarceration of uveal tissue
- 18. TYPES • Anterior • Intercalary •Ciliary • Equatorial • Posterior
- 19. Anterior staphyloma • Partialor total • Mostly after sloughed cornea • AC becomes flat with secondary glaucoma • Iris is incarcerated in anterior staphyloma
- 20. Intercalary staphyloma • Limbus •Root of iris and anterior most part of ciliary body • Externally from limbus to 2mm behind • Caused by: 1. perforating injury at peripheral cornea involving limbus, 2. marginal corneal ulcers, 3. anterior scleritis, 4. scleromalacia perforans, 5. complicated cataract surgery with wound dehisence, secondary glaucoma
- 21. Ciliary staphyloma • Affectsciliary zone - upto 8 mm behind the limbus • Scleral ectasia with incarceration of ciliary body • Caused by: 1. developmental glaucoma, 2. end stage of primary or sec glaucoma, 3. scleritis, 4. trauma to ciliary region of eye
- 22. Equatorial staphyloma • Equatorialregion of eye with incarceration of choriod • 14 mm behind the limbus weak area due to passage of venae vorticosae • Caused by: 1. scleritis , 2. chronic uncontrolled glaucoma, 3. degenerative myopia
- 23. Posterior staphyloma • Posteriorpole of eye lined by choroid • Degenerative high myopia • Detected by fundoscopy and B- scan ultrasonography
- 24. Treatment • Treat thecause • Small –local excision with corneo-scleral graft (tectonic graft) • Large unsightly blind eyes are enucleated and replaced with implant
- 25. BLUE SCLERA 1. Inchildren. 2. In high myopia. 3. In Buphthalmos. 4. Over a staphyloma. 5. Osteogenesis imperfecta a syndrome of : a) Deafness (otosclerosis). b) Fragility of bones. c) Blue sclera.