SCLERA
SCLERITISSTAPHYLOMA
Objectives: • Basic anatomy of the sclera.
• Etiology, types & clinical features of episcleritis & scleritis.
• Management of episcleritis & scleritis.
• Define staphyloma.
• Types of staphyloma & their causes.
Collagen bundles
– Varying size
– Varying shape
– Less uniform orientation than cornea
– Inner layer blends with uveal tract
Vascular layers
• Conjunctival vessels – Most superficial
• Superficial Episcleral vessels – Within Tenon’s capsule
• Radial configuration
• Deep Vascular plexus – Lies adjacent to sclera
Episcleritis
Clinical Features:
• Common• Benign• Self-limiting• Recurrent• Never progresses to scleritis• Rarely associated with systemic disease
Classification
• Simple episcleritis – Sectoral redness – Diffuse redness – Resolves in 1-2 weeks
• Nodular episcleritis – Focal, raised, nodular – Sclera uninvolved – Longer to resolve
Management :
Mild cases • Usually no specific Rx• – If discomfort • Lubricant • Topical NSAID eg acular (keterolac) • Mild topical corticosteroid (e.g. Fluconazole)
Recurrent or unresponsive cases
• – Systemic NSAID – e.g. Ibuprofen• – Refer for investigation if 3 or more recurrences
Scleritis
Relatively rare
Granulomatous inflammation
Mild to blinding spectrum
Classification
Anterior Scleritis
Posterior Scleritis
Non-necrotizing
diffuse nodular
Necrotizing
with inflammation
without inflammation
Associated systemic diseases
Rheumatoid Arthritis Connective Tissue Disease - Wegener granulomatosis - Systemic lupus erythematosus - Polyarteritis nodosa Herpes Zoster Ophthalmicus Miscellaneous - Surgically induced - Infectious
Anterior Scleritis: non-necrotizing
1. Diffuse scleritis
• Widespread redness• Sectorial or entire ant. Sclera• Loss of radial vessel pattern of sclera• Does not progress to nodular or necrotizing• Relatively benign
2. Nodular Scleritis
• On initial assessment like episcleritis• Scleral nodule immobile• Tender to palpation
Management:
• Oral NSAID (Ibuprofen)
• Oral Prednisone (if intolerant or unresponsive to NSAIDS)
• Combined therapy
• Immunosuppressives Cyclophosphamide, azathioprine or cyclosporine in steroid resistant cases
Manage in conjunction with a physician
Anterior necrotizing scleritis:with inflammation
• Severe form of disease• Gradual onset• Pain and local redness
Clinical signs
1. Distortion & occlusion of BVs2. Avascular patches in episcleral tissue3. Scleral necrosis4. Underlying uvea visible5. Necrosis spreads, may become confluent6. Anterior uveitis
Treatment
• Oral prednisone 1mg/kg/day Or Pulsed IV Methylprednisolone (500-1000mg)
Monitor pain in first 2-3 days Taper dose of steroids to response• Immunosuppressives Cyclophosphamide, azathioprine or cyclosporine in steroid resistant cases
Manage in conjunction with a physician
Anterior necrotizing scleritis:without inflammation
Scleromalacia perforans
Asymptomatic Mainly in females with longstanding RhA Commences with yellow necrotic scleral patch Large areas of uvea eventually exposed Spontaneous perforation rare No effective treatment
Posterior Scleritis
arising posterior to the equator
• Maculopathy• Optic neuropathy• Exudative retinal detachment
Clinical signs
• External eye– eyelid oedema– proptosis– ophthalmoplegia
• Ophthalmoscopy– Disc swelling– Macular oedema– Exudative retinal detachment
• Other signs– Vitritis– Choroidal folds– Subretinal exudates
Investigations
Ultrasonography : Thickening of choroid & sclera Oedema of Tenons space T-sign No mass lesion
CT scan Fluorescein angiography
Treatment
Elderly patients with systemic disease - treat as necrotizing anterior scleritis
Young patients without systemic disease - treat with NSAIDS
STAPHYLOMA
Ectasia of the outer coats of the eye with incarceration of uveal tissue.
Weakening of the eye wall with raised intraocular pressure
Anterior staphyloma
• Cornea
• Sequelae of corneal ulcer
Intercalary staphyloma
• Upto 8 mm behind limbus
• Incarceration of ciliary body
• Developmental glaucoma• End stage glaucoma (pri / sec)• Scleritis • Trauma to ciliary region
Equatorial staphyloma
• 8-14 mm behind the limbus
• Scleritis• Pathological myopia• Chronic uncontrolled glaucoma
Posterior staphyloma
• Posterior pole of the eye
• Pathological myopia
• Define staphyloma
• Name the different tyes of staphyloma
• Give one common cause for each type of staphyloma
• Give the classification of scleritis
• Any two DD for nodular episcleritis
Suggested reading
• Etiology, clinical features and management of Episcleritis
• Etiology, classification, clinical features and management of Scleritis
• Types & etiology of staphyloma.
• Treatment of anterior scleritis. Ocular complications of the treatment
Thank you