Transcript Scleritis & Episcleritis

EPISCLERITIS/
SCLERITIS
LT COL Ayyaz Hussain Awan TI(M)
MBBS, DO, FCPS
Assistant Prof
EPISCLERA
• Dense vascular connective tissue; which merges with
superficial scleral stroma
• Rich blood supply -> Ant. Ciliary Arteries, Long &
short post ciliary arteries.
SCLERA STROMA
• Dense fibrous tissue intermingled with elastic tissue
• Irregularly arranged collagen fibers Opacity of sclera
• Visco elastic structure
• Biphasic response to deforming force
brief lengthening (elastic response)
slow stretching (viscid response)
LAMINA FUSCA (Suprachoroid lamina)
APPLIED ANATOMY
Sclera
is covered with three vascular layers
• The conjunctiva vessels  Most superficial
• The superficial episcleral vessels  within tenon capsule
and have redial configuration
• The deep vascular plexus  adjacent to sclera
Functions of sclera
• Protection of intra ocular contents from trauma & mechanical
displacement.
• Preservation of shape of eye ball.
• Maintenance of exact position of different parts of
optical system
• Rigid insertion for extra ocular muscles
EPISCLERITIS AND SCLERITIS
1. Episcleritis
• Simple
• Nodular
2. Anterior scleritis (98%- 85% + 13%)
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Non-necrotizing diffuse
Non-necrotizing nodular
Necrotizing with inflammation
Necrotizing without inflammation
( scleromalacia perforans )
3. Posterior scleritis (2%)
Applied anatomy of vascular coats
Normal
• Radial superficial
episcleral vessels
• Deep vascular plexus
adjacent to sclera
Episcleritis
• Maximal congestion
of episcleral vessels
Scleritis
• Maximal congestion of
deep vascular plexus
• Slight congestion of
episcleral vessels
Episcleritis
• Common, benign, self-limiting but frequently recurrent.
Young adults, unilateral mild discomfort,tenderness
• Seldom associated with a systemic disorder
Simple sectorial episcleritis
Simple diffuse episcleritis
Treatment
• Topical steroids
• Systemic flurbiprofen (100 mg tid) if unresponsive
SCLERITIS
“Granulomatons inflammation of sclera” characterized
by oedema and cellular infiltration of the entire
thickness of sclera.
Ranges from mild self-limiting episode of inflammation to
severe necrotizing process which may lead to sight threatening
Complications like

Uveitis

Cataract

Keratitis

Retinal edema

Optic neuropathy
SCLERITIS
– Causes and associations :
In 50% of cases
• Rheumatoid arthritis
• Connective tissue disorders
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–
–
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Wegner granulomatous
Relapsing polychondritis
Polyarteritis nodosa
SLE
SURGICALLY INDUCED
INFECTIOUS SCLERITIS
Pseudomonas aeruginosa, Strep. Pneumoniae, Stap.
Aureus, Varicella zoster virus
ANTERIOR NON-NECROTIZING
SCLERITIS
Similar to episclertitis, although discomfort is more severe
 Inflammation involves deep vascular plexus
 2.5% Isonephrine ( Phenylephrine) test
 NODULAR SCLERITIS:
– Mimics diffuse scleritis
– Nodule can’t be moved
over underlying tissue
– 25% cases having
visual impairment
ANTERIOR NONNECROTIZING 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: (Only for nonnecrotizing type)
• Triamcinolone acetonide (40mg/ml)
ANTERIOR NECROTIZING SCLERTIS
WITH INFLAMMATION
 Gradual Pain which becomes severe and persistent, radiates to
temple, brow or jaw, frequently interferes with sleep.
 Occlusion of blood vessels and appearance of an avascular
patch which may coalesce with other separate necrotic areas.
 Scleral necrosis that may be associated with overlying
conjunctival ulceration & visibility of underlying uveal tissue.
 Associated anterior uveitis.
 Bilateral in 60% cases, asymmetrical.
 Mortality rate - 25% within 5 yrs.
ANTERIOR NON-NECROTIZING
SCLERITIS WITH
INFLAMMATION
 COMPLICATIONS:
– Staphyloma formation
– Perforation sec. to severe scleral thinning
– Anterior uveitis:
• Long standing uveitis may result into
– Sec. cataract
– Glaucoma
– Macular oedema
 Poor prognosis
 High incidence of visual impairment
ANTERIOR NON-NECROTIZING
SCLERITIS WITH INFLAMMATIN
 TREATMENT
– Oral prednisolone :
60-120 mg daily for 23 days
– Immunosuppresive agents:
• Cyclophosphamide
• Azathioprine
• Cyclosporin
 Combined therapy:
• I/V methyl prednisolone 500-1000 mg + cyclophosphamide
500mg
ANTERIRO NECROTIZING SCLERITIS WITHOUT
INFLAMMATION
(SCLEROMALACIA PERFORANS)
 Typically affects women with long standing rheumatoid arthritis
 Necrotic patch followed by melting of sclera
 Underlying uvea becomes visible
 Asymptomatic
 No effective treatment
Posterior scleritis
• Pain, Decreased vision, Lid oedema and fullness.
• 20% of all cases of scleritis ,30% of patients have systemic disease
• Treatment similar to necrotizing scleritis with inflammation
Proptosis and
ophthalmoplegia
Ring choroidal
detachment
Disc swelling
Choroidal folds
Exudative retinal
detachment
Subretinal exudation
Imaging in posterior scleritis
Ultrasound
Axial CT
a
a
b
a - Thickening of posterior sclera
b -Fluid in Tenon space (‘T’ sign)
Posterior scleral thickening
ALLERGIC CONJUNCTIVITIS
1. Allergic rhino-conjunctivitis
• Seasonal
• Perrenial
2. Vernal kerato-conjunctivitis
3. Atopic kerato-conjunctivitis
ALLERGIC
RHINOCONJUNCTIVITIS
 MOST COMMON FORM OF OCULAR AND NASAL ALLERGY
 HYPERSENSITIVITY REACTION TO A SPECIFIC AIRBORNE
ALLERGEN
– SEASONAL ALLERGY
– PERENNIAL ALLERGY
 TRANSIENT ACUTE ATTACK OF
REDNESS, WATERING AND ITCHING
 CONJUNCTIVA HAS MILKY OR
PINKISH APPAEARANCE
 TREATMENT
TOPICAL MAST CELL STABILIZER
or ANTIHISTAMINE
VERNAL KERATOCONJUNCTIVITIS
COBBLESTONE PAPILLAE
GIANT PAPILLAE
RECURRENT, BILATERAL, OCULAR INFLAMMATION
BOYS AND YOUNG ADULTS IN WARM, DRY CLIMATES
AN ALLERGIC DISORDER WHERE IgE AND CELL
MEDIATED IMMUNE MECHANISMS PLAY AN
IMPORTANT ROLE
Limbal vernal
Mucoid nodule
Trantas dots
VERNAL KERATOCONJUNCTIVITIS
Punctate epitheliopathy
Plaque formation (shield ulcer)
Epithelial macro-erosions
Sub-epithelial scarring
VERNAL
KERATOCONJUNCTIVITIS
 PSEUDOGERONTOXON
 TREATMENT
• STEROIDS
• MAST CELL STABILIZERS
• ANTIHISTAMINES
• SUPRATARSAL STEROID INJECTION
ATOPIC KERATOCONJUNCTIVITIS
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
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Recurrent, Bilateral, Ocular Inflammation, Warm Dry Climates
Young Patients With Atopic Dermatitis
Eyelids Are Red, Thickened, Macerated And Fissured
An Allergic Disorder, IgE And Cell Mediated Immune Mechanism
 TREATMENT
– Topical:
• Preservative Free Lubricants
• Steroids
• Mast Cell Stabilizers
– Supratarsal Steroid Inj.
– Systemic
• Antihistamines
• Antibiotics
ATOPIC KERATOCONJUNCTIVITIS
Infiltration of tarsal conjunctiva causing featureless appearance
Inferior forniceal papillae
Mild symblepharon formation
BLISTERING
MUCOCUTANEOUS DISEASES
 CICATRICIAL PEMPHIGOID
 STEVENS-JOHNSON SYNDROME
OCULAR CICATRICIAL PEMPHIGOID
Idiopathic, Subepidermal / Subepithelial Blistering And Scarring
Autoimmune Disease
Subconjunctival bullae
Ulceration and formation of pseudomembranes
Subepithelial fibrosis
SYMBLEPHARON
ANKYLOBLEPHARON
OCULAR CICATRICIAL PEMPHIGOID
TOTAL CORNEAL
KERATINIZATION
SECONDARY BACTERIAL
KERATITIS
OCULAR CICATRICIAL
PEMPHIGOID
 TREATMENT
– TOPICAL
• STEROIDS
• TEAR SUBSTITUTES
• ANTIBIOTICS
– SUBCONJUNCTIVAL MITOMYCIN-C INJECTION
– SILICONE CONTACT LENS
– SYSTEMIC TREATMENT (REQUIRED IN
MAJORITY OF CASES)
• STEROIDS
• DAPSONE
STEVENS-JOHNSON
SYNDROME
 ACUTE, SEVERE, MUCOCUTANEOUS
BLISTERING DISEASE
 PRESENTATION
– FEVER, MALAISE, SORE THROAT, COUGH
– CRUSTY EYELIDS
– CONJUNTIVITIS WITH PATCHY CONJUNCTIVAL
INFARCTION
– NO FURTHER SCARRING OCCURS FOLLOWING
THE ACUTE PHASE
STEVENS-JOHNSON SYNDROME
RESIDUAL FOCAL
ACUTE CONJUNCTIVITIS CONJUNCTIVAL FIBROSIS
COMPLICATIONS
Symblepharon, Epiphora, Dry eyes, Keratopathy
TREATMENT
Systemic & topical steroids
Acyclovir if herpes simplex is suspected