Sclera

Dr. Binto Akturusiano, SpM

Anatomy of The Sclera

Composed primarily of type I collagen and
proteoglycans
Avascular, execpt :
superficial vesels of the episclera
intrascleral vascular plexus at posterior of the
limbus

Anteriorly, consists of dense vascular

connective tissue

Hypersensitivity Reaction and

Ocular Disease
Type I ( Anaphylactic or Atopic Reactions)
An antigen binds with two adjacent IgE --->
release of histamine and other mediator

Type II (Cytotoxic Hypersensitivity)

Interaction of immunoglobines with antigens
--> cell lysis by complement activation
Killer cells are involved in antibodydependent
cell cytotoxity

 Type III (Immune-Complex Reactions)

follows the deposition of antigen-antibody
complexes in ocular tissue with complement
activation and neutrophil recruitment

Type IV (Delayed Hypersensitivity)

Antigens inter act with receptors on the surface
of T lymphocytes and result in the release of
lymphokines

Hypersensitivity Reactions and

Ocular Disease
Type
I
dermatitis
II
III
IV

Ocular Disease
Allergic conjungtivitis
Atopic keratoconjungtivitis &
Ocular cicatrical pemphigoid
Mooren ulcer
Scleritis
Contact dermatitis
Phlyctenulosis

Inflammation of the Sclera

Episcleritis
benign inflammatory of the deep
subconjungtival connective tissues
occasionally fleeting, frequently repeated
(episcleritis periodica fugax)

 E/ : allergic reaction to an endogenous toxin

Clinical finding :
Dense lymphatic infiltration of the subconjunctival
and episcleral tissues

 Little or no pain, usually there is a feeling of

discomfort and tenderness on pressure, often
severe neuralgia
Treatment :
corticosteroid drops/ointment
NSAID drops

 Scleritis
bilateral, occurred most frequently in women
more rare than episcleritis
may extend entirely round the cornea, forming
a very serious condition known as annular
scleritis
sometimes extend to cornea causing slerosing
keratitis
E/: immune-mediated vasculitis that inflames
and destroys the sclera
associated with systemic disease :
SLE, polyarteritis nodosa

 Clinical presentation
The swelling is at first dark red or bluish, later
it becomes purple and semi transparent
Onset usually gradual over several days
Subtypes And Prevalence of Scleritis
Location
Anterior sclera

Posterior sclera

Subtype
Diffuse scleritis
Nodular scleritis
Necrotizing scleritis
with inflammation
without inflammation

Prevalence
40%
44%
14%
(10%)
(4%)
2%

 Diffuse or nodular anterior scleritis

characterized by scleral edema and redness zone
scleral nodule is a deep red to purple colour, immobile,
and separated from the overlying episcleral tissue
which is elevated by the nodule

 Necrotizing scleritis
the most destructive form
a localized patch of inflammation with the edge of
lesion more inflamed than the center
sclera becomes blue-gray appearance and an altered
deep episcleral blood vessel pattern

 Necrotizing scleritis without signs of

inflammation (scleromalacia perforans)
in patiens with long-standing rheumatoid
arthritis (55% of cases)
signs are minimal and generally no pain
sclera thins and the underlying dark uveal
tissue become visible --> uvea is covered with
only thin connective tissue and conjunctiva

 Posterior scleritis

occur in isolation or concomitant with anterior scleritis

signs are pain, tenderness, proptosis, visual loss and
restricted motility, retraction of the lower eyelid caused
by infiltration of muscle in the region of posterior
scleritis
pain maybe reffered to other other parts of head --> D/
can be missed

Complications of scleritis
Complication are frequent and include :

peripheral keratitis (37%)

uveitis (30%)
cataract (7%)
glaucoma (18%)
scleral thinning (33%)

anterior uveitis as spillover phenomenon :

anterior scleritis
posterior uveitis : ant and post scleritis

Management of Scleritis
In mild cases of diffuse anterior & nodular
scleritis : topical corticosteroid
NSAID (indomethacine, naproxen, diclofenac,
etc) are also effective
Oral and high dose IV steroid may be effective
in necroting sleritis sclerokeratitis

Congenital Anomalies of Sclera

Blue Sclera
Related to generalized thinning with increased
visibility of underlying uvea
Syndromes associated with :
Osteogenesis imperfecta type I
Ehlers-Danlos syndrome type VI (EDS VI)
EDS VI with normal lysyl hydroxylase

 Clinical findings : All three syndrome share each other

Management : regular hearing evaluation after
adolescence

Degenerative Process of the

Sclera
Senile Plaques
E/:
scleral reigidity
decrease of scleral hydration
decrease of mucopolysaccharide

Accompanied by subconjungtival deposition of fat

The plaques do not elicit inflammation and rarely
extrude