Diseases of sclera

Diseases of sclera
2. anatomy • Sclera  posterior 5/6th opaque part of the external fibrous tunic of the eyeball.
3. • outer surface }covered by Tenon's capsule. • anterior part } covered by bulbar conjunctiva.
4. Its inner surface lies in contact with choroid with a potential suprachoroidal space in between
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. Apertures of sclera • Anterior • Anterior ciliary vessels • Middle • four vortex veins (vena verticosae) • Posterior • Optic nerve • Long & short ciliary nerves
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.

1. Diseases of sclera

2. anatomy
•Sclera posterior 5/6
th
opaque part of
the external fibrous tunic of the eyeball.

3. •outer surface }covered by Tenon's capsule.
•anterior part } covered by bulbar conjunctiva.

4. Its inner surface lies in contact with choroid
with a
potential suprachoroidalspace in between

6. Thickness of sclera.
•thinner }children and in females Sclera
•thickest} posteriorly (1mm)
•gradually becomes thin when traced anteriorly.
•thinnest } insertion of extraocularmuscles (0.3 mm).
•Lamina cribrosais a sieve-like sclera from which fibres of optic nerve
pass.

7. Apertures of sclera
•Anterior
•Anterior ciliaryvessels
•Middle
•four vortex veins(venaverticosae)
•Posterior
•Optic nerve
•Long & short ciliarynerves

8. 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 suprachoroidaland
supraciliary
laminaeof the uvealtract.
brownish in colour
presence of pigmented cells.

9. Inflammations of sclera
•Episcleritis(superficial)
•Scleritis(deep)

10. episcleritis
•benign recurrent inflammation of the episclera,
•involving the overlying Tenon's capsule
•but not the underlying sclera.

11. etiology
•Unknown
•Associated with gout/psoriasis/rosacea
•Hypersensitivity reaction to endogenous tubercular or streptococcal
toxins.

12. incidence
•M>f
•Young adults

13. pathology
•localised lymphocytic infiltration of episcleraltissue
•oedema and congestion of overlying Tenon's capsule and
conjunctiva.

14. symptoms
•by redness,
•mild ocular discomfort described as gritty, burning or
•foreign body sensation

15. 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.

16. 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 (episcleritisperiodica) may occur

17. DD
•Inflammedpinguecula
•Scleritis
•Fb reaction on bulbar conjunctiva

18. treatment
•1.Topical corticosteroid eyedrops2-3hourly,
•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

19. scleritis

20. scleritis
•c/c inflmnof sclera proper
•F>m
•Elderly

21. etiology
•Autoimmune collagen disordersRA(common),Wegener's
granulomatosis,PAN, SLE and ankylosingspondylitis.
•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'sdisease and rosacea
•Surgically induced scleritisocularsurgery. within 6 month postoperatively.
•Idiopathic

22. pathology
•infiltration by PMNL , lymphocytes, plasma cells and macrophages
•Fibrinoidnecrosis, destruction of collagen
•
•granuloma surrounded by multinucleated epitheloidgiant cells

23. classification
•I. Anterior scleritis(98%)
•1. Non-necrotizing scleritis(85%)
•(a) Diffuse
•(b) Nodular
•2. Necrotizing scleritis(13%)
•(a) with inflammation
•(b) without inflammation (scleromalaciaperforans)
•II. Posterior scleritis(2%)

24. 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.

25. 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

26. •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).

27. •3. Anterior necrotizing scleritiswith inflammation.
•acute severe form of scleritis
•characterised by intense localised inflammation
•associated with areas of infarction due to vasculitis
•necrosedsclera thinned out (sclera becomes transparent and
ectatic) with uvealtissue shining through it.
•Anterior uveitis+

28. •Anterior necrotizing scleritiswithout inflammation (scleromalacia
perforans).
•elderly females with long-standing RA.
•yellowish patch of melting sclera (due to obliteration of arterial
supply);
•with overlying episcleraandconjunctivacompletely separates from
the surrounding normal sclera.
•Eventually absorbs leaving behind it a large punched out area of
•thin sclera through which the uvealtissue shines
•Spontaneous perforation rare

29. •posterior scleritis.
•the sclera behind the equator.
•frequently misdiagnosed.
•associated inflammation of adjacent structures,
•exudative retinal detachment,
•macular oedema,
•proptosisand
•limitation of ocular movements.

30. complications
•2’ glaucoma (due to uveitis…)
•Complicated cataract
•sclerosingkeratitis,
•keratolysis

31. 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. Mantouxtest.
•7. X-rays of chest, paranasalsinuses, sacroiliac joint and orbit to rule
out foreign body especially in patients with nodular scleritis.

32. Treatment
•(A) Non-necrotising scleritis
•Topical steroid eyedropsand
•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
•Subconjunctivalsteroids are contraindicated because they may lead to scleral
thinning and perforation

33. Blue sclera

34. Blue sclera
•asymptomatic condition
•marked, generalised blue discolouration of sclera due to thinning.
osteogenesisimperfecta.
Marfan'ssyndrome,
Ehlers-Danlossyndrome,
pseudoxanthomaelasticum,
buphthalmos,
High myopia and
healed scleritis.

35. staphylomas

36. staphylomas
•localised bulging of weak and thin outer tunic of the eyeball (cornea
or sclera),
•lined by uvealtissue which shines through the thinned out fibrous
coat.

37. classification
•Anterior
•Intercalary
•Ciliary
•Equatorial
•posterior

38. Anterior staphyloma
•Ass. With ectasiaof cornea & iris
•Due to perforating corneal ulcer & injury

39. 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 limbalarea lined by root of iris

40. •marked corneal astigmatismDefective vision
•2’angle closure glaucomaprogressionof swelling
•Treatment
•localised staphylectomyunder heavy doses of oral steroids.

41. Ciliarystaphyloma
•bulge of weak sclera lined by ciliarybody.
•about 2-3 mm away from the limbus
•thinning of sclera following perforating injury,
•scleritisand absolute glaucoma.
Ciliarystaphyloma

42. 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= scleritisand degeneration of sclera in pathological myopia

43. Posterior staphyloma
•bulge of weak sclera lined by the choroid behind the.
•common causes are pathological myopia, posterior scleritisand
perforating injuries.
•Diagnosisophthalmoscopy.
•The area is excavated with retinal vessels dipping in it (just like
•marked cupping of optic disc in glaucoma)