Diseases of the Sclera
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Transcript of Diseases of the Sclera
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
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