EPISCLERITIS/SCLERITIS

ANATOMY
 HISTOLOGY

Lamina
Sclera: fusca
Melanocytes
 5/6 posterior SCLERA
 White opaque Loose episcleral
 Insertion of extra ocular CT
proper
muscle
 3 layers:
 Episclera
 Stroma
 Lamina fuscha
stroma
 EPISCLERA
• Outermost layer ……nutrition to sclera

• low friction surface

• Loose connective tissue

• Rich blood supply -> superficial n deep ant plexus

posterior episcleral plexus

• Superficial plexus n Conjunctival vessels mainly involved

in inflammation…..blanch with topical vasoconstictors

 SCLERAL STROMA
• Dense fibrous tissue intermingled with elastic tissue

• Complete sphere of 22 mm diameter

• Irregularly arranged collagen fibers make it opaque n tough

• Visco elastic structure

• Biphasic response to deforming

force brief lengthening (elastic

response) slow stretching

 LAMINA FUSCA

• Inner most layer

• Faintly brown due to melanocytes

• Separates it from external surface of choroid

 EPISCLERITIS
It is a common, benign self limiting and
frequently recurrent disorder which
typically affects young females

May be associated with underlying

disease(10%)
Can be divided into
– Simple
– Nodular
 EPISCLERITIS

– PRESENTATION
Unilateral redness
Mild discomfort/ tenderness
Watering
Photophobia….may be present
– SIGNS:
SIMPLE EPISCLERITIS:
–Commonest type
–Sectoral /diffuse redness
–Resolves spontaneously in 1-2
weeks
 EPISCLERITIS
NODULAR EPISCLERITIS:

– Localized ,raised ,congested

nodule
– Takes longer time to
resolve Sclera not
swollen
Sclera appears translucent
Nodular episcleritis
EPISCLERITIS Differential diagnosis
Phlyctenular
conjunctivitis

Conjunctivitis

Scleritis
 EPISCLERITIS
TREATMENT:
– Not always required
– Reassurance / cold compressions
– Simple lubricants
– Topical steroids
May lead to recurrence
Frequent intense instillation on short term pulse
based
– Oral NSAIDs :
Flurbiprofen 100 mg t.i.d
 SCLERITIS
It is characterized by edema and
cellular infiltration of the entire
thickness of sclera.
Much less common than episcleritis
Older age group
Trivial……….sight threatening
condition
 Causes of Scleritis
Causes and associations :50% of cases
1.Autoimmune diseases

Ankylosing spondylitis.
Rheumatoid arthritis
Wegner’s granulomatosis.
Systemic lupus erythematosis.
Psoriatic arthritis.
Ulcerative colitis
2.Granulomatous diseases

T.B
Syphilis
Sarcoidosis
Leprosy
 Causes of Scleritis
SURGICALLY INDUCED.
INFECTIOUS SCLERITIS:
– Spread of infection from corneal
ulcer
– Trauma
– Excision of a pterygium or adjunctive
B irradiation or mitomycin C
– Causative agents:
Pseudomonas aeruginosa
Strep. Pneumoniae
Stap. Aureus
Varicella zoster virus
 SCLERITIS
INFECTIOUS SCLERITIS:

– Spread of infection from corneal ulcer

– Trauma
– Excision of a pterygium or adjunctive B
irradiation or mitomycin C
– Causative agents:
Pseudomonas aeruginosa
Strep. Pneumoniae
Stap. Aureus
Varicella zoster virus
 SCLERITIS
Anatomical classification:

– Anterior scleritis (98%)

Non-necrotizing (85%) : diffuse or nodular

Necrotizing (13%) : with or without

inflammation
– Posterior scleritis (2%)
ANTERIOR NON-NECROTIZING
SCLERITIS
PRESENTATION:
– Similar to EPISCLERITIS
– More severe discomfort

SIGNS:
– A. DIFFUSE SCLERITIS:
Relatively benign condition
Wide spread inflammation
Involves a sector or entire sclera
Characteristic distortion of normal radial
vascular pattern
ANTERIOR NON-NECROTIZING
SCLERITIS
NODULAR SCLERITIS:

– High association with HZO

– Nodule can’t be moved over
underlying tissue
– Intermediate severity
– 25% cases having visual
impairment
ANTERIOR NON-NECROTIZING
SCLERITIS
TREATMENT:
– Oral NSAIDS : flurbiprofen 100 mg t.i.d
meloxicam 7.5 mg t.i.d
– Oral prednisolone : 40-80 mg daily
– Combined therapy
– Subconjunctival steroid injections:
Triamcinolone acetonide (40mg/ml)
Only for non-necrotizing type
 ANTERIOR NECROTIZING
SCLERITIS WITH INFLAMMATION

Most severe and distressing form

Bilateral in 60%
Not necessarily simultaneous
There may be associated vascular
disease
Mortality rate of 25% within 5 yrs of
onset
 ANTERIOR NECROTIZING
SCLERITIS WITH INFLAMMATION

PRESENTATION:

– Gradual onset of pain and localized redness

– Pain becomes severe and persistent and
radiates to temple ,brow or jaw
– Frequently interferes with sleep
– Responds poorly to analgesia
 ANTERIOR NECROTIZING
SCLERITIS WITH INFLAMMATION
SIGNS:
Vaso-occlusive :
 Assosciated with RA
 Isolated patches of scleral edema with overlying
non perfused episclera and conjunctiva
 Patches coalesce….scleral necrosis
 Granulomatous:
 Associated with WG n PAN
 Start from limbus extend posteriorly
 Within 24 hr involve conjunctiva , episclera ,
sclera
 ANTERIOR NON-NECROTIZING
SCLERITIS WITH INFLAMMATION
COMPLICATIONS:
– Staphyloma formation
– Scleral thinning…….Perforation
– Kerartitis: acute infiltrative,sclerosing,PUK
– Anterior uveitis:
Long standing uveitis may result into
– Sec. cataract
– Glaucoma
– Macular oedema
Poor prognosis
High incidence of visual impairment
 ANTERIOR NECROTIZING
SCLERITIS WITH INFLAMMATIN
TREATMENT
– Oral prednisolone : 60-120 mg daily for 2-
3 days
– Immunosuppresive agents:
Cyclophosphamide
Azathioprine
Cyclosporin

Combined therapy:
I/V methyl prednisolone 500-1000 mg + cyclophosphamide
500mg
ANTERIOR NECROTIZING SCLERITIS
WITHOUT INFLAMMATION
Also known as scleromalacia perforans
In women with long standing rheumatoid arthritis
Usually bilateral

SIGNS:
– Asymptomatic yellow necrotic patches in uninflammed sclera
– Enlargement ,spread and coalescence
– Progressive exposure of underlying uvea as a result of scleral
thinning
– Staphyloma formation may occur
– Spontaneous perforation is rare unless IOP is raised

TREATMNENT is ineffective
 POSTERIOR SCLERITIS
Uncommon, often misdiagnosed
Affects women twice as often as men 1/3
rd patients are under 40 yrs of age at
presentation
Patients over 50 yrs: at inc. risk of harbouring
systemic disease and suffering visual loss 2/3
rd cases have unilateral involvement
Guarded visual prognosis
Visual impairment to some degree in 1/3 rd
cases
 POSTERIOR SCLERITIS
PRESENTATION:

– Variable
– Depends upon exact site of involvement
– Most common symptoms are pain and visual impairment
SIGNS :

– EXTERNAL :
Lid oedema and fullness
Proptosis and ophthalmoplegia
Associated ant. Scleritis in 1/3 rd cases
 POSTERIOR SCLERITIS
INTERNAL :

– Disc swelling
– Macular oedema
– Choroidal folds
– Exudative retinal detachment
– Ring choroidal detachment
– Subretinal lipid exudation
 POSTERIOR SCLERITIS
INVESTIGATIONS:
– ULTRASONOGRAPGHY:
Thickening of post sclera
Fluid in Tenon space – “T” sign
Stem of “T” is formed by optic n.
Cross bar by gap containing fluid in sub-Tenon
space

– CT SCAN:
Post scleral thickening
 POSTERIOR SCLERITIS
USG / CT FINDINGS

Thickening of
posterior sclera
 POSTERIOR SCLERITIS
DIFFERENTIAL DIAGNOSIS:

OPTIC NEURITIS
RHEGMATOGENOUS RD
CHOROIDAL TUMOUR
 POSTERIOR SCLERITIS
TREATMENT:
– In elderly patients with associated systemic
disease, as for necrotizing anterior scleritis

– Young patients without associated systemic

disease usually respond well to NSAIDs
 Clinical
Episclerit Scleriti
• Abrupt is -Days to weeks • Insidious
s ove
• Redness –
severa days r
irritatio
without l
•n Mil ocula discomfo
• palpation
Pain, tendernes
radiat to
d-Burning,
r rt
FB
• Worse
, ats e
sensatio irritatio
night+awak
n, n
• Localized e