SLERITIS in detail including anterior and posterior

Scleritis

1. Scleritis

2. CBME OP.NUMBER COMPETENCY DOMAIN LEVEL CORE 5.2 DEFINE ENUMERATE AND DESCRIBE THE ETIOLOGY, ASSOCIATED SYSTEMIC CONDITION,CLINICAL FEATURES,COMPLICATION AND INDICATION FOR REFERRAL AND MANAGEMENT OF SLERITIS K KH Y

3. Introduction to Scleritis Definition: Scleritis is a serious inflammatory disease affecting the white outer coating of the eye (the sclera). May cause visual impairment and even loss of the eye if treated inadequately. It usually occurs in elderly patients (40-70 years) involving females more than the males.

4. Causes of Scleritis Overall about 50% cases of scleritis are associated with some systemic diseases, most common being connective tissue diseases.

5. Autoimmune collagen disorders Metabolic disorders Infections Rheumatoid arthritis Wegener's granulomatosis Polyarteritis nodosa (PAN), SLE Ankylosing spondylitis. Gout Thyrotoxicosis Herpes zoster ophthalmicus Chronic staphylococcal Streptococcal infection

6. Granulomatous diseases Miscellaneous condition Surgically induced sleritis Tuberculosis Syphilis Sarcoidosis Leprosy Irradiation Chemical burns Vogt- Koyanagi -Harada syndrome Behcet's disease Rosacea Rare It occurs within 6months postoperatively.

7. Classification Immune-mediated non-infectious, scleritis Infectious scleritis Non-necrotizing scleritis (85%) Diffuse Nodular Necrotizing scleritis Anterior scleritis (98%) Posterior scleritis (2%) With inflammation 1.vaso-occlusive 2. Granulation 3. Surgically induced Without inflammation ( scleromalacia perforans )

8. Symptoms of Scleritis Pain- Moderate to severe Deep and boring in character Often wakes the patient early in the morning. Radiates to the jaw and temple. Redness may be localized or diffuse with violaceous hue. Photophobia and lacrimation may be mild to moderate. Diminution of vision may occur occasionally.

9. SIGNS Anterior scleritis a. Non-necrotizing anterior scleritis 1. Non-necrotizing anterior diffuse scleritis. It is the commonest variety, characterized by widespread inflammation involving a quadrant or more of the anterior sclera. The involved area is raised and salmon pink to purple in colour .

10. 2. Non-necrotizing anterior nodular scleritis. It is characterized by one or two hard, purplish elevated immovable scleral nodules, usually situated near the limbus Sometimes, the nodules are arranged in a ring around the limbus (annular scleritis).

11. b. Necrotizing anterior scleritis with inflammation. 1 Anterior necrotizing scleritis It is an acute severe form of scleritis characterised by intense localised inflammation associated with areas of infarction due to vasculitis. The affected necrosed area is thinned out and sclera becomes transparent and ectatic with uveal tissue shining through . It is usually associated with anterior uveitis.

12. 2. Necrotizing anterior scleritis without inflammation. Typically occurs in elderly females usually suffering from long-standing rheumatoid arthritis. Characterised by development of yellowish patch of melting sclera. Together with the overlying episclera and conjunctiva completely separates from the surrounding normal sclera. This sequestrum of sclera becomes dead white in colour , which eventually absorbs leaving behind it a large punched out area of thin sclera through which the uveal tissue shines

13. lI. Posterior scleritis. It is an inflammation involving the sclera behind the equator. The condition is frequently misdiagnosed. It is characterised by features of associated inflammation of adjacent structures, which include: exudative retinal detachment, macular oedema, proptosis and limitation of ocular movements.

14. B.Infectious scleritis • Infectious scleritis accounts for 5-10% of all cases. • In the early stage, diagnosis becomes difficult as presentation is similar to as non-infectious scleritis. •Scleritis with purulent exudates or infiltrates should raise the suspicion of an infectious etiology. • Formation of fistulae, painful nodules, conjunctival and scleral ulccers are usually signs of infectious scleritis.

15. Complication Complications are more common with necrotizing than the non-necrotizing scleritis and include: • Corneal: Sclerosing keratitis, keratolysis and peripheral ulcerative keratitis • Scleral: Thinning, without and with bulging (staphyloma formation) • Uveal: Uveitis • Secondary glaucoma si not uncommon • Lens: Complicated cataract • Retinal and optic nerve complications occur in posterior scleritis and include macular oedema, disc oedema, and exudative retinal detachment • Hypotony may occur in long standing scleritis with uveitis • Proptosis may occur in posterior scleritis, usually there is associated limitation of ocular movements.

16. Investigation • TLC, DLC and ESR. • Serum levels of complement (C3), rheumatoid facto immune complexes, r, antinuclear antibodies and L.E cells for an immunological survey. • FIA-ABS, VDRL for syphilis. • Serum uric acid for gout. • Urine analysis. • Mantoux test. • X-rays of chest, paranasal sinuses, sacroiliac joint and orbit (to rule out foreign body especially in patients with nodular scleritis).

17. Treatment A. Non-infectious scleritis I. Non-necrotizing scleritis. It is treated by: • Topical steroid eye drops • Systemic indomethacin 75 mg twice a day until inflammation resolves.

18. ll. Necrotizing scleritis. It is treated by: • Topical steroids • Oral steroids on heavy doses, tapered slowly. •Immunosuppressive agents like methotrexate or cyclophosphamide may be required in non-responsive cases. •Subconjunctival steroids are contraindicated because they may lead to scleral thinning and perforation. • Surgical treatment, in the form of scleral patch graft may be required to preserve integrity of the globe in extensive scleral melt and thinning.

19. B. Infectious scleritis Most of the time diagnosis is delayed and patients are put on topical and oral steroids which worsen the infective Treatment includes: •Antimicrobial therapy, both with topical and oral agents si required in an aggressive manner. •Surgical debridement is found useful by debulking the infected s.cleral tissue and also facilitating the effect of antibiotics

20. Indication for referral Scleral melting- corneal specialist opinion Collagen disorders- rheumatologist opinion Granulomatous diseases- physician opinion

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