Objectives

To discuss basic anatomy of the sclera

To determine common diseases affecting the sclera

To know the work up and management of specific diseases affecting the sclera

Anatomy

Thickness of Sclera

Thickest posteriorly (1mm)

Thinnest at the insertion of EOMs ( 0.3 mm )

0.4 mm to 0.6 mm at the equator

0.8 mm at the limbus

Special Regions of the Sclera Scleral Sulcus Scleral spur Lamina cribosa

Scleral Spur

Lamina Cribosa

Scleral Apertures

Nerve Supply

Long ciliary nerves anteriorly

Short ciliary nerves behind the equator

Blood Supply

Microscopic Structures

Biochemical CompositionCornea vs Sclera

Cornea Sclera

Water content 78% 70%

Composition 4.5 % GAGs 75 % collagen; 20 % other CHONS; almost absent glycosaminoglycans

Lamellae Uniform arrangement from 30 nm diameter and 60 nm center

Wide variation in diameter (30 to 300 nm) & irregularly spacing in the sclera

Swelling pressure 60 mm Hg 10 to 17 mm Hg

Episcleritis

Benign, self limited inflammation of the episclera

20-50 years old Underlying systemic cause is found

only minority of cases Ocular redness without irritation Seen most commonly in the

exposure zone of the eye

Episcleritis

Types of Episcleritis

episcleritis

simple nodular

Nodular Episcleritis

Diffuse Episcleritis

Scleritis

Immune mediated vasculitis Frequently associated with

underlying systemic immunologic disease

4th to 6th decades of life Women

Scleritis

Gradual onset Severe boring or piercing ocular pain Tenderness of the globe Violaceous hue over inflamed sclera Scleral vessela has criss-cross

pattern

Types of Scleritis

Anatomical locationAppearance of scleral inflammation

Anterior scleritis

Posterior scleritis

Necrtozing scleritis with inflammation

Necrotizing scleritis without inflammation

Nodular Non- Necrotizing Scleritis

Diffuse anterior Scleritis

Necrotizing Scleritis

Necrotizing Scleritis without Inflammation (Scleromalacia Perforans)

Posterior scleritis

Anterior variant of inflammatory pseudotumor

Pain, tenderness, proptosis, visual loss and restricted motility

Complications: Choroidal folds, exudative retinal

detachment, papilledema, & angle closure glaucoma

Posterior Scleritis

Complications of Scleritis Peripheral keratitis (37%) Uveitis (30%) Cataract (7%) Glaucoma (18%) Scleral thinning (33%)

Sclerokeratitis

Scleral Thinning

Diagnostic EvaluationAssociated Factors Suspected Disease Laboratory Tests

Arthritis, back pain, GI/genitourinary symptoms

Seronegative spondyloarthropathies

HLA-B27, sacroiliac films

Shortness of breath, African descent, subcutaneous nodules

SarcoidosisSerum ACE, lysozyme, chest x-ray or chest CT scan, gallium scan, biopsy

History of HIV, alcohol abuse, exposure to infected individuals, residence in endemic regions

TBPurified protein derivative (PPD), chest x-ray, referral to infectious disease specialist

Sexually active; (+) Chancre, HIV Syphylis Rapid plasma reagent (RPR) or VDRL, FTA-ABS

Malar rash, joint& kidney problems; Female

SLE ANA, Anti-Dna

Swan neck deformity of joints

Tenderness of the temporal area

Rheumatoid Arthritis

Temporal arteritis

ESR, RF

Tempoarl artery biopsy, ESR

Management

Episcleritis

No Pain With Pain

OBSERVElubricants

Topical or oral NSAIDSCorticosteroids (short course)

ManagementScleritis

Non necrotizing

Oral NSAIDS

Necrotizing

Oral or IV Corticosteroids (1st line)Antimetabolite (Methotrexate)Immunomodulator (Cyclosporine)Cytotoxic agent (Cyclophosphomide)

SYSTEMIC LAB WORK-UP IS NEEDED

One hundred thirty-four patients with scleral inflammation were seen over a 12-year period. Thirty-seven patients had episcleritis, and 97 patients had scleritis.

Ocular complications occurred in only 13.5% of patients with episcleritis but in 58.8% of patients with scleritis

, Abdulbaki Mudun, MDa, J.P. Dunn, MDa, Marta J. Marsh, MSa

Episcleritis and scleritis: clinical features and treatment resultsDouglas A. Jabs, MD, MBAab

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Necrotizing scleritis and posterior scleritis more often were associated with ocular complications, occurring in 91.7% and 85.7%, respectively, than were diffuse anterior scleritis and nodular anterior scleritis

Patients with necrotizing scleritis and posterior scleritis were more likely to be treated with oral corticosteroids or immunosuppressive drugs (90% and 100%, respectively) than were patients with diffuse anterior scleritis and nodular anterior scleritis

Episcleritis and scleritis: clinical features and treatment resultsDouglas A. Jabs, MD, MBAab

Posterior scleritis is relatively uncommon and is often misdiagnosed due to its protean manifestations

Fundus findings included serous retinal detachment, choroidal folds, retinal folds, subretinal mass, choroidal detachment, disc edema, and macular edemaPosterior scleritis: Clinical profile and imaging characteristics

Jyotirmay Biswas, Sangeet Mittal, Sudha K Ganesh, Nitin S Shetty, Lingam Gopal. Medical Research Foundation, Chennai, India

There was associated anterior scleritis and anterior uveitis in the majority of the cases

In all cases ultrasound with or without CT scan confirmed the clinical diagnosis.

All patients responded to systemic steroids except one who required immunosuppressive therapy

Posterior scleritis: Clinical profile and imaging characteristicsJyotirmay Biswas, Sangeet Mittal, Sudha K Ganesh, Nitin S Shetty, Lingam Gopal. Medical Research Foundation, Chennai, India

Surgically induced necrotizing scleritis has been reported to occur after cataract extraction, trabeculectomy, squint surgery. Pterygium surgery and retinal detachement surgery

In SINS, there is variable latent period betwee surgery and the presentation may vary from day1 to 40 years

Surgically Induced scleritis Nickil Gokhale M.D et al; Indian Journal of Ophthalmology

The area of scleral melts develops adjacent to the wound and may extend to involve the whole anterior segment

Autoimmunity or hypersensitivity is now believed to be the etiological factor

Treatment is immunosupressionSurgically Induced scleritis Nickil Gokhale M.D et al; Indian Journal of Ophthalmology

Thank You!