Ophthalmology Notes: SCLERA & CONJUNCTIVA

SCLERITIS

DEF-

Edema & cellular infiltration of entire scleral thickness.

CAUSES-
1.Systemic-
* RA
* Wegener’s granulomatosis
* Relapsing polychondritis
* PAN

2.Surgery-
* Cataract surg
* RD surg
* Filtration surg
* pterygium excision + beta radiation + MMC

3.Infections-
* Corneal ulcer
*Trauma
* Org- Pseudo aeruginosa, strep pneumo, staph aureus, varicella zoster

CLASS-

Anterior scleritis-

Non-necrotizing-Diffuse or nodular
Necrotizing- With or without inflamn

2.Posterior scleritis

ANTERIOR NON-NECROTIZING SCLERITIS-

1 ]Diffuse scleritis-

* Inv a sector or entire anterior sclera

* Distorts the nml radial vascular pattern

2] Nodular scleritis-

* Scleral nodule cannot be moved over the underlying tiss

* Dark red or bluish, later purple

T/T-

1.Oral NSAIDs

2.Oral steroids

3. Steroids + NSAIDs

4.S/C Triamcinolone acetonide 40mg/ml

ANTERIOR NECROTIZING SCLERITIS-

WITH INFLAMMATION-

Localized redness
Pain-radiates to temple,brow or jaw
Congestion of deep vascular plexus.
Vascular distortion & occlusion → avascular patches
Scleral necrosis with overlying conj ulceration
Resolution → scleral thinning→uvea visible as bluish tinge
COMPLICATIONS-Staphyloma

-Cataract

-Keratitis

-Keratolysis

-Sec glaucoma

-Macular edema

T/T-

1.Oral steroids

2.Immunosuppressives-

Cyclophosphamide-1-2 mg/kg/day

Azathioprine-1-3mg/kg/day

Cyclosporin-2-5 mg/kg/day

3.Combined therapy-

Pulsed IV methylprednisone 1gm + cyclophosphamide 500mg

WITHOUT INFLAMN -

Also k/as –SCLEROMALACIA PERFORANS

Asymptomatic yellow ,necrotic,scleral patches in uninflamed sclera
Scleral thinning→ exposes uvea
Staphyloma
T/T- ineffective

POSTERIOR SCLERITIS-

C/F-

Pain
Visual impairment
Lid edema
Proptosis
O’plegia
Asstd ant scleritis
Fundus-Disc edema, mac edema,choroidal folds,exud RD,Ring choroidal det& subretinal lipid exud

INV-

USG-“ T” sign-Thickening in post sclera & fld in tenon’s space.
Stem of T is formed by optic N & cross-bar by fluid in subtenon’s space
CT SCAN- Posterior scleral thickening

T/T- same

SCLERA & CONJUNCTIVA

EPISCLERITIS

DEF-

Benign inflamn of subconj connective tiss & superficial scleral lamella.

Young adults
Females
H/O RA

TYPES- Simple

-Nodular

C/F-

Symptoms-UL

-Acute redness

-discomfort

-tenderness

-watering

Signs-

1.SIMPLE EPISCLERITIS-

a] Sectoral OR

B] Diffuse

* D/T engorgement of large episcleral Vs running in a radial dir beneath the conj

* Never ulcerate

* Cor & uvea NOT inv

* May resolve or leave a slate coloured scar to which conj is adherent

2.NODULAR EPISCLERITIS-

* Localized, raised , congested nodule

* Ant scleral surf is not raised

* Traversed by deeper episcleral Vs.So look purple & not red.

T/T-1. Lubricants

2.Topical steroids

3. NSAIDs- T. Flurbiprofen 100mg tds

- OR t. Aspirin

- T. Indomethacin

SCLERITIS [j-01, d-02, j-04]

DEF-

Edema & cellular infiltration of entire scleral thickness.

CAUSES-

1.Systemic-

* RA

* Wegener’s granulomatosis

* Relapsing polychondritis

* PAN

2.Surgery-

* Cataract surg

* RD surg

* Filtration surg

* pterygium excision + beta rad + MMC

3.Infections-

* Corneal ulcer

*Trauma

* Org- Pseudo aeruginosa, strep pneum, staph aureus, varicella zoster

CLASS-

Anterior scleritis-

Non-necrotizing-Diffuse or nodular
Necrotizing- With or without inflamn

2.Posterior scleritis

ANTERIOR NON-NECROTIZING SCLERITIS-

1 ]Diffuse scleritis-

* Inv a sector or entire anterior sclera

* Distorts the nml radial vascular pattern

2] Nodular scleritis-

* Scleral nodule cannot be moved over the underlying tiss

* Dark red or bluish, later purple

T/T-

1.Oral NSAIDs

2.Oral steroids

3. Steroids + NSAIDs

4.S/C Triamcinolone acetonide 40mg/ml

ANTERIOR NECROTIZING SCLERITIS-

WITH INFLAMN-

Localized redness
Pain-radiates to temple,brow or jaw
Congestion of deep vascular plexus.
Vascular distortion & occlusion → avascular patches
Scleral necrosis with overlying conj ulceration
Resolution → scleral thinning→uvea visible as bluish tinge
COMPLICATIONS-Staphyloma

-Cataract

-Keratitis

-Keratolysis

-Sec glaucoma

-Macular edema

T/T-

1.Oral steroids

2.Immunosuppressives-

Cyclophosphamide-1-2 mg/kg/day

Azathioprine-1-3mg/kg/day

Cyclosporin-2-5 mg/kg/day

3.Combined therapy-

Pulsed IV methylprednisone 1gm + cyclophosphamide 500mg

ANTERIOR NECROTIZING SCLERITIS

WITHOUT INFLAMN-

Also k/as –SCLEROMALACIA PERFORANS

Asymptomatic yellow ,necrotic,scleral patches in uninflamed sclera
Scleral thinning→ exposes uvea
Staphyloma
T/T- ineffective

POSTERIOR SCLERITIS-

C/F-

Pain
Visual impairment
Lid edema
Proptosis
O’plegia
Asstd ant scleritis
Fundus-Disc edema, mac edema,choroidal folds,exud RD,Ring choroidal det& subretinal lipid exud
INV-

USG-“ T” sign-Thickening in post sclera & fld in tenon’s space.Stem of T is formed by optic N & cross-bar by fld in subtenon’s space

CT SCAN- Posterior scleral thickening

T/T- same

STAPHYLOMA-case

DEF-

Ectasia of outer coats of the eye with an incarceration of uveal tissue

Underlying cause is inflammation / degeneration

CLASS-

Anterior
Intercalary
Ciliary
Equatorial
Posterior

ANTERIOR STAPHYLOMA-

Partial- Part of cornea inv
Total-Whole of cornea inv
MCC- Sloughing corneal ulcer→ perforates → Heals & forms pseudocor by exudative organization & laying down of fibrous tissue
Lined internally by iris & externally by epith
AC-flat
Sec glaucoma dev later
Gradually weak ant surf of eye protrudes out→ Ant staphyloma

INTERCALARY STAPHYLOMA-

Located at the limbus
Lined by iris root & ant part of CB
Seen externally from the limbus upto 2mm behind the limbus
Causes-

Perforating inj of peripheral cor
Marginal cor ulcer
Ant scleritis
Scleromalacia perforans
Complicated cataract surg with poor wound apposition
Sec glauc

3.CILIARY STAPHYLOMA-

* Affects the ciliary zone [8mm behind the limbus]

* CB is incarcerated in scleral ectasia

* Bluish & lobulated

Causes-

1.Dev glauc

2.End stage glauc

3.Scleritis

4.Trauma to ciliary region

4.EQUATORIAL STAPHYLOMA-

* Occurs at the equatorial reg with incarceration of choroid [14mm behind the limbus]

* Equator is Weak d/t passage of venae vorticosae

Causes-

Scleritis
deg myopia
Chr uncontrolled glauc

POSTERIOR STAPHYLOMA-

Posterior pole of eye
Lined by choroid
MCC- deg high axial myopia
Ectatic portion detected externally
Fundus-Crescentic shadow in macular region

-Retinal Vs change dir dipping into the region

*Staphylomatous area- pale d/t deg in ret, RPE &

Choroid

T/T-

T/T of underlying cause
Local excision & repair with corneal & scleral patch graft
Unsightly & blind eye-Staphylectomy & KP

OR Enucleation + implant

PARTS OF CONJUNCTIVA-

1. Palpebral-

Marginal
Tarsal
Orbital

2.Fornix

3.Bulbar

4.Limbal

MICROSCOPIC-

EPITHELIUM

Palpebral conj- 2 layers of epith
Intermarginal strip-Transitional stratified squamous epith
From fornix to limbus-4-6 layers
Limbus- stratified epith

SUB-EPITHELIAL / ADENOID LAYER-

Loose connective tiss + leucocytes

C . FIBROUS LAYER

XEROPHTHALMIA-WHO CLASS-

XN- Nightblindness

XIA- Conjunctival xerosis

XIB- Bitot’s spots

X2- Corneal xerosis

X3A- Corneal ulceration/keratomalacia <1/3rd cor surf

X3B- Corneal ulceration / keratomalacia > 1/3rd cor surf

XS- Corneal scar

XF- Xerophthalmic fundus [UYEMURA’S FUNDUS]

Night blindness is also k/as –Chicken eyes [since chickens lack rods & are nightblind]

CONJUNCTIVAL CONGESTION	CILIARY CONGESTION
Bright red	Dull red
Near the fornix	Around the limbus
Branch dichotomously	Branch radially
Arise from post conj Vs	Arise from anterior ciliary Vs
Phenylepherine→ blanch	Do not blanch
Vs fill up from the fornix	Vs fill up from the limbus
Superficial inv-c’vitis, simple hyperaemia	Deep inv-iritis, scleritis

TRUE PTERYGIUM	PSEUDOPTERYGIUM
Degenerative	Inflammatory
Usually progressive	Stationary
Probe cannot be passed underneath the head of pterygium	Probe can be passed.

FOLLICLES-

Localised aggregation of lymphocytes in the subepithelial adenoid layer.

CAUSES-

HSV conjunctivitis
molluscum contagiosum c’vitis
chlamydial inf
Parinaud’s oculoglandular syn

Q Diff bet trachomatous folliclec & follicles in follicular conjunctivitis?

A- Trachomatous follicles- 5mm dia

-Commence in lower fornix

-Form a row along upper tarsal margin

-Undergo cicatrisation & form minute

Stellate scars.

PAPILLAE-

Hyperplasia of central Vs surrounded by diffuse infiltrates of lymphocytes,plasma cells & eosinophils

CAUSES-

Chr blepharitis
Vernal catarrh
Giant papillary c’vitis
contact lens induced
Superior limbic keratoconjunctivitis

FOLLICULAR CONJUNCTIVITIS [d-04]

1.Acute

2.Subacute / chronic

ACUTE FOLLICULAR CVITIS-

Chlamydial inclusion conjunctivitis
Epidemic keratoconjunctivitis
Pharyngoconj fever
Newcastle cvitis
H’hic cvitis
Primary herpetic cvitis
Recurrent herpes simplex cvitis

SUBACUTE /CHRONIC

Drug induced [pilocaropine]
Sec to lid lesions-moll contagiosum,pediculosis
Trachoma

1) CHLAMYDIAL INCLUSION CVITIS-

Agent-Chlamydia trachomatis[D-K]
Spread-genitals,eye-eye,swimming pool
C/F- UL/BL mucopurulent discharge
SIGNS-large follicles in lower fornix→2-3wks→SPK + pannus
T/T-

Topical tetracycline e/o qid for 6wks
Tab doxy 100mg 12hrly for 2wks
Tab erythro 250mg 12 hrly for 2wks
Tab. Azithro 1gm OD

2) EPIDEMIC KERATOCONJUNCTIVITIS-

Agent- Adenovirus 8 & 19
Spread- contaminated fingers,sol,tonometer
C/F –Foll cvitis

-Preauricular LNpathy

-Punctate epith infiltrates

-discrete subepith opacities

* T/T- Decongestive & lubricating drops

-Antibiotic e/d

3) PHARYNGOCONJUNCTIVAL FEVER-

Agent-adenovirus3,4&7
C/F-
Foll cv
Pharyngitis
Fever
Preaur LNpathy
SPK

4) NEWCASTLE CV

contact with diseased fowls
indistinguishible from others

5) H’GHIC CV

picorna v , coxsackie v & entero v
C/F-VIOLENT INFLAM CV
LACRIMATION
Photophobia
Subconj h’age
Preaur LNpathy

6) ACUTE HERPETIC CV

Prim herpes
preaur LNpathy
corneal vesicles→ merge→ dendritic figures
large follicles
reduced cor sensation

7) RECURRENT HERPES SIMPLEX CV

Acute foll cv without lesions of face,lids or cor
Microdendrites
Reduced cor sensation
T/T-

Artificial tears
acyclovir e/o 3% 5 /day
Vidarabine e/o 3% 5/d
Trifluorothymidine 1 % e/d 5/d

VERNAL CATARRH [j-04, d-02]

Also k/as vernal c’vitis or spring catarrh
EPIDEMIO- Recurrent

-Sporadic

-non-contagious

-BL

-Hot weather

-Young boys

-F/H of atopy

-Type –I hypersensitivity-Ig E mediated

-eosinophilia

* C/F-

-Burning

-Itching

-Photophobia

-Lacrimation

-White ropy discharge [b/o fibrin]

2 forms-1] Palpebral

2] Limbal / Bulbar

PALPEBRAL-

Palp conj is hypertrophied [papillae]& mapped out into polygonal raised areas like cobblestones
Bluish –white like milk
Flat topped nodules are hard & consist of dense fibrous tiss.The overlying epith is thickened,therefore milky hue.

BULBAR-

Wall of gelatinous thickening at the limbus
HORNER TRANTAS DOTS-white dots consisting of eosinophils & epith debris

COMPLICATIONS-

SPK
Dry eyes
Corneal [ shield] ulcer
Scarring

T/T-

Cold compression & tinted glasses
Antihistaminic e/d
Topical steroid e/d 4-6 hrly
Disodium chromoglycate e/d 2% 8 hrly or 4% 12 hrly
Olopatadine e/d BD- new mast cell stabilizer
Subtarsal inj of triamcinolone
Acetyl cysteine 10 % or 20 % drops-for excess mucus
Cryotherapy of nodules

ANTI-ALLERGIC DRUGS [j-07]

H1- RECEPTOR ANTAGONIST [ANTIHISTAMINICS]

Competetively inhibit histamine at the receptor sites

IND-

VKC
GPC
Allergic cvitis

TOPICAL-

Emedastine qid
Levocabastine
Azelastine OD or BD
Antazoline qid
Chlorpheniramine qid

SYSTEMIC-

Loratidine
Cetrizine
Astemizole
Fexofenadine

MAST CELL STABILIZERS-

Stabilize the membrane of mast cells→ prevent release of histamine

Cromolyn sodium-

-2-4 % E/D 6 hrly

- 2 % oint HS

- Ind- VKC

-GPC

- onset of action- 3-4 weeks

Ketotifen –

TDS
Quicker onset of action

Lodoxamide-

- 0.1 % TDS

Olopatadine-

0.1 % 12 hourly
Antihistaminic + mast cell stabilizer

Others- pemirolast , nedocromil sodium

3] ANTIHISTAMINES + MAST CELL STABILIZERS-

* Olopatadine

* Ketotifen [ anti-inflam]

* Azelastine [ “ ]

4] NSAIDs

- Ketorolac- Reduces itching

- but stinging

5] VASOCONSTRICTORS-

-Naphazoline / pheniramine

- Naphazoline / Antazoline

6] STEROIDS-topical

- Loteprednol

- Flurometholone

- Rimexolone