SCLERITISSCLERITISDr.Fuad A K Niazi,

Assistant Professor,

Rawalpindi medical college,

Department of Ophthalmology,

Holy Family Hospital.

ScleritisScleritis

OBJECTIVESOBJECTIVES

• Definition

• Incidence

• Classification

• Signs & Symptoms.

• Specific investigations.

• Treatment

DEFINITIONDEFINITION

Scleritis is a granulomatous inflammation of the sclera.

ScleritisScleritis

EpiscleritisEpiscleritis

IncidenceIncidence

It is much less common than episcleritis.

Women are commonly affected in the 5th and 6th decade.

Usually bilateral.

PathologyPathology

• There is dense infiltration of the scleral tissue by lymphocytes.

ClassificationClassification

1.Anterior scleritis(95%)

a.Non-necrotizing:diffuse or nodular

b.Necrotizing: with or without inflammation

2.Posterior scleritis(5%)

Associated Systemic Diseases

Associated Systemic Diseases

• 45% of patients may have the following associated diseases:

1.Rheumatoid arthritis

2.Connective issue disorders

3. Miscellaneous: relapsing polychondritis,herpes zoster,gout,surgically induced scleritis etc

CLINICAL FEATURESCLINICAL FEATURES

Anterior non-necrotizing scleritis

Anterior non-necrotizing scleritis

1.Presentation: Severe discomfort,tenderness and watering of eyes.

2.Signs: a)Diffuse scleritis-Widespread inflammation Distortion of vascular pattern Benign progression

b)Nodular Scleritis-Nodular appearance Intermediate severity

Anterior diffuse scleritisAnterior diffuse scleritis

Anterior nodular scleritisAnterior nodular scleritis

Anterior necrotizing scleritis with inflammation

Anterior necrotizing scleritis with inflammation

1.Presentation: Most severe form with gradual onset of pain and localized redness .

2. Signs: a) Distortion or occlusion of blood vessels b) Development of scleral necrosis c) Gradual spread of necrosis around the globe d) Presence of associated anterior uveitis indicative of very severe disease involving ciliary body

Complications: corneal involvement,cataract,glaucoma.

Anterior necrotizing scleritis with inflammationAnterior necrotizing scleritis with inflammation

Anterior necrotizing scleritis without

inflammation

Anterior necrotizing scleritis without

inflammation1. Presentation: Asymptomatic

2. Signs: Starts with a yellow necrotic patch Large areas of uvea become exposed

3. Complications: Perforation rare unless IOP elevated

Anterior necrotizing scleritis without inflammation(scleromalacia perforans)Anterior necrotizing scleritis without

inflammation(scleromalacia perforans)

Posterior scleritisPosterior scleritis

• Presentation: Variable,pain and visual impairment

• Signs: Eyelid oedema Proptosis

Opthalmoplegia Associated anterior scleritis present in 40% of cases

• Ophthalmoscopy: Disc swelling Macular oedema Retinal detachment Vitritis Ring Choroidal detachment

Choroidal folds Subretinal mass Intraretinal white deposits

Posterior scleritisPosterior scleritis

Posterior scleritis(cont…)Posterior scleritis(cont…)

• D/D: Optic neuritis Rhegmatogenous RD Choroidal tumour Orbital inflammatory disease or mass Uveal effusion syndrome Harada disease

• USG: Thickening of posterior sclera with fluid in tenon space

• CT: Thickening of posterior sclera with fluid in tenon space

Choroidal folds over maculaChoroidal folds over macula

B-scanB-scan

TreatmentTreatment

• ANTERIOR NON-NECROTIZING SCLERITIS: Oral NSAIDS(flurbiprofen 100mg x tds) Oral prednisolone(40-80mg x od) Combination therapy of NSAIDS and lower dose steroids.

• ANTERIOR NECROTIZING SCLERITIS WITH INFLAMMATION: Oral prednisolone(60-120mg x od tapered accordingly) Immunosuppressive agents Combined therapy with pulsed i.v methylprednsolone(500-1000mg) and cyclophosphamide(500mg)

Treatment(cont…)Treatment(cont…)

• ANTERIOR NECROTIZING SCLERITIS WITHOUT INFLAMMATION: No effective treatment

• POSTERIOR SCLERITIS: a)Elderly patients with associated systemic disease are treated in the same way as those with anterior necrotizing scleritis. b)Young patients without associated systemic disease usually respond well to NSAIDS.

Surgical treatmentSurgical treatment

• Extreme scleral thinning requires reinforcement.

• Corneal marginal ulceration or keratolysis may require

corneal grafting.