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Definition :

  • Scleritis refers to the inflammed condition of the Sclera proper.
  • It is comparitively severe when compared to episcleritis.
  • Most importantly it causes visual impairment and even leads to loss of eye when treated inadequately.
  • But fortunately, the incidence of Scleritis is very less when compared to that of episcleritis.
  • Above all scleritis usually occurs in elderly patients of age group ranging from 40 to 70 years.
  • And moreover the incidence is common in females than that in males.

Characteristic features :

  • Age : Mostly in elderly females
  • Pain : Moderate to severe
  • Colour : Violaceous hue
  • Blanching test with 10% Phenylephrine : Negative
  • Lesion : Raised, non-necrotizing/necrotizing
  • Course : Long

Etiology/Causes of Scleritis:

  • About half of the cases are associated with the systemic diseases.
  • Moreover most common diseases leading to this condition is Connective tissue diseases.
  • Common conditions involved are
    • Autoimmune collagen diseases
      • Rhematoid arthritis
      • Wegener’s granulomatosis
      • Polyarteritis nodosa
      • Systemic lupus erythematosus
      • And also ankylosing spondylitis
    • Metabolic disorders
      • Gout
      • Thyrotoxicosis
    • Infections
      • Herpes zoster ophthalmicus
      • Chronic staphylococcal infection
      • And also chronic streptococcal infection
    • Granulomatous diseases
      • Tuberculosis
      • Syphilis
      • Sarcoidosis
      • In addition Leprosy
    • Surgically induced scleritis
      • Rare complication
    • Miscellaneous
      • Irradiation
      • Chemical burns
      • Vogt-Koyanagi-Harada syndrome
      • Behcet’s disease and also
      • Rosacea
    • Finally the cause may also be Idiopathic

Scleritis

Pathology of Scleritis :

  • Firstly, histopathological changes of the condition are that of a Chronic granulomatous disorder.
  • They are characterized by fibrinoid necrosis and also by destruction of collagen.
  • They are also presented with infiltration by polymorphonuclear cells, lymphocytes, plasma cells and macrophages.
  • Further, multinucleated epithelioid giant cells surround the granuloma.
  • Moreover, old and new blood vessels surround the granuloma.
  • Above all these bloods vessels may also show evidence of vasculitis.

Classification :

  • Immune mediated non-infectious type
  • And also Infectious type

Immune mediated non-infectious scleritis :

  • Immune mediated non-infectious type is further classified into Anterior type and posterior type.
  • Further the anterior type is classified into Non-necrotizing type and necrotizing type.
  • Further the necrotizing type is classified into Diffuse and Nodular type.
  • The necrotizing type is further classified based on the presence/absence of inflammation.
  • Moreover the necrotizing type with inflammation is further classified into Vaso-occlusive, Granulomatous and Surgically induced.
  • The above type without inflammation is also called Scleromalacia perforans.

TYPES OF SCLERITIS :

Non-Necrotizing anterior diffuse scleritis The most commenest type.
And also characterized by widespread inflammation involving a quadrant or more of anterior sclera.
Involved area is raised and salmon pink to purple in colour.

Non-Necrotizing anterior nodular scleritis

 

It is characterized by one or two hard, purplish elevated immovable scleral nodules.
Moreover, it is usually situated near the Limbus.
In addition, the nodules are arranged in a ring around the limbus.
And so it is also called Annular scleritis.
Anterior necrotizing scleritis with inflammation Characterized by intense localised inflammation associated with areas of Infarction due to Vasculitis.
The affected necrosed area is thinned out and sclera becomes thinned out.
And therefore the sclera becomes transparent and ectatic with the uveal tissue shining through it.
This condition is usually associated with anterior uveitis.
Anterior necrotizing without scleritis Occurs usually in the elderly females.
And specifically those females suffering from Rheumatoid arthritis for a longer period of time.
It is characterized by yellowish patch of melting sclera.
Posterior scleritis It is an inflammation involving the sclera behind the equator.
It is characterized by features associated with inflammation of adjacent structures.
The characteristic features include Exudative retinal detachment, Macular oedema, Proptosis and limitation of ocular movements.
Infectious scleritis Firstly, it is very difficult to distinguish it from non-necrotizing scleritis in the early stages.
Secondly, they are characterized by the foramation of fistulae.

Complications :

  • Complication are more common in necrotizing type.
  • The complications involves Cornea, Sclera, Uveal tract, lens, Retinal and optic nerve, proptosis and also Hypotony.
  • Cornea :
    • Sclerosing keratitis, keratolysis and also Ulcerative keratitis.
  • Sclera :
    • Thinning, Without and With bulging
  • Uveal tract :
    • Uveitis
  • Moreover secondary glaucoma is not uncommon.
  • Lens :
    • Complicated cataract
  • Retinal and Optic nerve complications :
    • Occurs in Posterior scleritis
    • Macular edema
    • Disc edema
    • And also exudative retinal detachment
  • Hypotony may occur in long steady scleritis along with Uveitis.
  • Finally, Proptosis may occur in posterior type.

Investigations :

  • TLC, DLC and ESR
  • Serum levels of complement C3, Immune complexes, Rheumatoid factor, Antinuclear antibodies and also LE cells for an immunological survey.
  • FTA-ABS and also VDRL for Syphilis.
  • Serum uric acid for gout.
  • Urine analysis.
  • Mantoux test.
  • Moreover the X-Rays of chest, paranasal sinuses, sacroiliac joint and also orbit are also preferred.

Treatment :

  • Non-infectious scleritis :
    • Topical steroid eye drops
    • And also systemic indomethacin
  • Necrotizing scleritis :
    • Topical steroids
    • And also oral steroids on heavy doses, tapered slowly.
    • Immunosuppressive agents like Methotrexate or Cyclophosphamide.
    • Contraindication – Subconjuctival steroids
    • And also surgical treatment.

Infectious scleritis :

  • Delayed diagnosis.
  • And therefore topical steroids or Oral steroids treatment is carried out.
  • Antimicrobial therapy
    • Topical agents
    • Oral agents
  • Finally, Surgical debridement.

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