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