EPISCLERITIS/ SCLERITIS

2. EPISCLERITIS/SCLERITIS LT COL Ayyaz Hussain Awan TI(M) MBBS, DO, FCPS Assistant Prof

3. 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)

4. 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

5. EPISCLERITIS AND SCLERITIS 1. Episcleritis • Simple • Nodular 2. Anterior scleritis (98%- 85% + 13%) • Non-necrotizing diffuse • Non-necrotizing nodular • Necrotizing with inflammation • Necrotizing without inflammation • ( scleromalacia perforans ) 3. Posterior scleritis (2%)

6. Applied anatomy of vascular coats Episcleritis Scleritis Normal • Maximal congestion of • deep vascular plexus • Radial superficial • episcleral vessels • Maximal congestion • of episcleral vessels • Deep vascular plexus • adjacent to sclera • Slight congestion of • episcleral vessels

7. nodular episcleritis

8. 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

9. 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

10. SCLERITIS • Causes and associations : In 50% of cases • Rheumatoid arthritis • Connective tissue disorders • Wegner granulomatous • Relapsing polychondritis • Polyarteritis nodosa • SLE SURGICALLY INDUCED INFECTIOUS SCLERITIS Pseudomonas aeruginosa, Strep. Pneumoniae, Stap. Aureus, Varicella zoster virus

11. 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

12. 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: (Only for non-necrotizing type) • Triamcinolone acetonide (40mg/ml)

13. 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.

14. 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

16. ANTERIOR NON-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

17. 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

18. scleromalacia perforans

19. 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 Exudative retinal detachment Disc swelling Ring choroidal detachment Choroidal folds Subretinal exudation

20. Imaging in posterior scleritis Ultrasound Axial CT a a b a - Thickening of posterior sclera Posterior scleral thickening b -Fluid in Tenon space (‘T’ sign)

21. ALLERGIC CONJUNCTIVITIS • Allergic rhino-conjunctivitis • Seasonal • Perrenial 2. Vernal kerato-conjunctivitis 3. Atopic kerato-conjunctivitis

22. 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

23. VERNAL KERATOCONJUNCTIVITISCOBBLESTONE 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

24. Limbal vernal Trantas dots Mucoid nodule

25. VERNAL KERATOCONJUNCTIVITIS Punctate epitheliopathy Epithelial macro-erosions Plaque formation (shield ulcer) Sub-epithelial scarring

26. VERNAL KERATOCONJUNCTIVITIS • PSEUDOGERONTOXON • TREATMENT • STEROIDS • MAST CELL STABILIZERS • ANTIHISTAMINES • SUPRATARSAL STEROID INJECTION

27. ATOPIC KERATOCONJUNCTIVITIS • 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

28. ATOPIC KERATOCONJUNCTIVITIS Infiltration of tarsal conjunctiva causing featureless appearance Mild symblepharon formation Inferior forniceal papillae

29. BLISTERING MUCOCUTANEOUS DISEASES • CICATRICIAL PEMPHIGOID • STEVENS-JOHNSON SYNDROME

30. OCULAR CICATRICIAL PEMPHIGOID Idiopathic, Subepidermal / Subepithelial Blistering And Scarring Autoimmune Disease Subconjunctival bullae Ulceration and formation of pseudomembranes Subepithelial fibrosis SYMBLEPHARON ANKYLOBLEPHARON

31. OCULAR CICATRICIAL PEMPHIGOID TOTAL CORNEAL KERATINIZATION SECONDARY BACTERIAL KERATITIS

32. 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

33. 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

34. STEVENS-JOHNSON SYNDROME ACUTE CONJUNCTIVITIS RESIDUAL FOCAL CONJUNCTIVAL FIBROSIS • COMPLICATIONS • Symblepharon, Epiphora, Dry eyes, Keratopathy • TREATMENT • Systemic & topical steroids • Acyclovir if herpes simplex is suspected

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