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Diseases of sclera ppt ophthalmology

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ophthalmology ppt

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Diseases of sclera ppt ophthalmology

  1. 1. Diseases of sclera
  2. 2. anatomy • Sclera  posterior 5/6th opaque part of the external fibrous tunic of the eyeball.
  3. 3. • outer surface }covered by Tenon's capsule. • anterior part } covered by bulbar conjunctiva.
  4. 4. Its inner surface lies in contact with choroid with a potential suprachoroidal space in between
  5. 5. 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.
  6. 6. Apertures of sclera • Anterior • Anterior ciliary vessels • Middle • four vortex veins (vena verticosae) • Posterior • Optic nerve • Long & short ciliary nerves
  7. 7. 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.
  8. 8. Inflammations of sclera • Episcleritis (superficial) • Scleritis(deep)
  9. 9. episcleritis • benign recurrent inflammation of the episclera, • involving the overlying Tenon's capsule • but not the underlying sclera.
  10. 10. etiology • Unknown • Associated with gout/psoriasis/rosacea • Hypersensitivity reaction to endogenous tubercular or streptococcal toxins.
  11. 11. incidence • M>f • Young adults
  12. 12. pathology • localised lymphocytic infiltration of episcleral tissue •  oedema and congestion of overlying Tenon's capsule and conjunctiva.
  13. 13. symptoms • by redness, • mild ocular discomfort described as gritty, burning or • foreign body sensation
  14. 14. 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.
  15. 15. 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
  16. 16. DD • Inflammed pinguecula • Scleritis • Fb reaction on bulbar conjunctiva
  17. 17. 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
  18. 18. scleritis
  19. 19. scleritis • c/c inflmn of sclera proper • F>m • Elderly
  20. 20. 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
  21. 21. pathology • infiltration by PMNL , lymphocytes, plasma cells and macrophages • Fibrinoid necrosis, destruction of collagen • • granuloma surrounded by multinucleated epitheloid giant cells
  22. 22. 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%)
  23. 23. 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.
  24. 24. 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
  25. 25. • 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).
  26. 26. • 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+
  27. 27. • 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
  28. 28. • 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.
  29. 29. complications • 2’ glaucoma (due to uveitis…) • Complicated cataract • sclerosing keratitis, • keratolysis
  30. 30. 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.
  31. 31. 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
  32. 32. Blue sclera
  33. 33. 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.
  34. 34. staphylomas
  35. 35. 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.
  36. 36. classification • Anterior • Intercalary • Ciliary • Equatorial • posterior
  37. 37. Anterior staphyloma • Ass. With ectasia of cornea & iris • Due to perforating corneal ulcer & injury
  38. 38. 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
  39. 39. • marked corneal astigmatism Defective vision • 2’angle closure glaucomaprogression of swelling • Treatment • localised staphylectomy under heavy doses of oral steroids.
  40. 40. 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
  41. 41. 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
  42. 42. 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)

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