SCLERA AND ITS DISEASES

DR. PREETI PATEL

 Introduction

Sclera forms the posterior five-sixth opaque

part of the external fibrous tunic of the eyeball.
 Its whole outer surface is covered by Tenon's
capsule.
In the anterior part it is also covered by bulbar
conjunctiva.
Its inner surface lies in contact with choroid
 thickness

Thickness of sclera varies considerably in different

individuals and with the age of the person.
It is generally thinner in children than the adults
and in females than the males.
Sclera is thickest posteriorly (1mm) and
gradually becomes thin when traced anteriorly.
 Lamina cribrosa is a sieve-like sclera from which
fibres of optic nerve pass
 Apertures

Sclera is pierced by three sets of apertures

 Posterior apertures :long and short ciliary nerves and
vessels.
 Middle apertures :four vortex veins (vena verticosae).
 Anterior apertures: Anterior ciliary vessels
 Microscopic structure.

Episcleral tissue
 It is a thin, dense vascularised layer of connective tissue which
covers the sclera proper.
Sclera proper
 It is an avascular structure which consists of dense bundles of
collagen fibres
Lamina fusca
 It is the innermost part of sclera which blends with
suprachoroidal and supraciliary laminae of the uveal tract.
 It is brownish in colour owing to the presence of pigmented cells
Nerve supply: branches from the long ciliary nerves
 Shirajala

जालाभः कठिनसिरो महान् सरक्तः सन्तानः स्मृत इह जालसञ्ज्ञितस्तु ||८||
A capillary net which is hard big, red colored and full
of blood Appears in shukla
Mandala
Lekhana and chedana karma
 Sirapidika

शुक्लस्थाः सितपिडकाः सिरावृता यास्ता विद्याद
सितसमीपजाः सिराजाः |९|su
दाहघर्षवत्यः सिरावृताः|
कृ ष्णासन्नाः सिरासंज्ञाः पिटिकाः सर्षपोपमाः||
१९||AH
A white nodule encircled
with capillary net develops
near the krishna mandala.
Chedana and
pratisarana
 Episcleritis

Recurrent inflammation of the episclera, involving

the overlying Tenon's capsule but not the underlying
sclera.
Etiology
 Exact etiology is not known.
 It is found in association with gout, rosacea and psoriasis.
 It has also been considered a hypersensitivity reaction to
endogenous tubercular or streptococcal toxins.
 Symptoms

Redness,
Mild ocular discomfort,
Burning or
Foreign body sensation
Mild photophobia
Lacrimation
 Signs

In diffuse episcleritis

 maximum inflammation is confined to one or two quadrants
In nodular episcleritis
 a pink or purple flat nodule: 2-3mm away from the limbus
 Treatment

Topical corticosteroid eyedrops instilled 2-3 hourly.

Cold compresses
Systemic non-steroidal anti-inflammatory drugs
 SCLERITIS

Scleritis refers to a chronic inflammation of the

sclera proper.
serious disease which may cause visual impairment
and even loss of the eye if treated inadequately
 Etiology

Autoimmune collagen disorders, especially rheumatoid

arthritis
Metabolic disorders like gout and thyrotoxicosis
Some infections, particularly herpes zoster ophthalmicus,
chronic staphylococcal and streptococcal infection
Granulomatous diseases like tuberculosis, syphilis,
sarcoidosis, leprosy
Miscellaneous conditions like irradiation, chemical burns

Surgically induced
 scleritis

Anterior(98%) Posterioer(2%)

Non necrotizing Necrotizing

With inflammation
Diffuse Without
Nodular inflammation
 Symptoms

moderate to severe pain

Ocular pain radiates to the jaw and temple
localised or diffuse redness,
mild to severe photophobia
lacrimation.
Occasionally diminution of vision.
Non-necrotizing anterior diffuse scleritis
 widespread inflammation involving a quadrant or more of the
anterior sclera
Non-necrotizing anterior nodular scleritis
 one or two hard, purplish elevated scleral nodules, usually
situated near the limbus
Anterior necrotizing scleritis with inflammation
 intense localised inflammation associated with areas of
infarction due to vasculitis
Anterior necrotizing scleritis without inflammation
 yellowish patch of melting sclera
 Investigations

TLC, DLC and ESR

FTA - ABS, VDRL for syphilis.
Serum uric acid for gout.
Urine analysis.
Mantoux test.
X-rays of chest, paranasal sinuses, sacroiliac joint
and orbit to rule out foreign body especially in
patients with nodular scleritis.
 Treatment

(A) Non-necrotising scleritis

 topical steroid eyedrops and
 systemic indomethacin 100 mg daily for a day and then 75 mg
daily until inflammation resolves.
(B) Necrotising scleritis.
 It is treated by topical steroid and heavy doses of oral steroids
tapered slowly.
 Balasgrathita

 कांस्याभो भवति सितेऽम्बुबिन्दुतुल्यः स ज्ञेयोऽमृदुररुजो बलासकाख्यः ||९||
 A soft painless nodule resemble like water bubbles and
shining like bronze develops in shukla mandala.
 Kaphaja abhisyanda vata chikitsa
 Sodhana
 Kshara anjana
 Pistaka

उत्सन्नः सलिलनिभोऽथ पिष्टशुक्लो बिन्दुर्यो भवति स पिष्टकः सुवृत्तः |८|
Circular ,Elevated dots or papules which look
like rice flour and fresh like water develop in
shukla mandala .
 anjana : sunthi+ pippali + musta +marich
+saindhva
Kahaja abhisyanda vata chikitsa
 PINGUECULA

 Degenerative condition of the conjunctiva.

 It is characterized by formation of a yellowish white
patch on the bulbar conjunctiva near the limbus.
Etiology of pinguecula is not known exactly.
 Occurring more commonly in persons exposed to
strong sunlight, dust and wind.
 Clinical features

yellowish white triangular patch near the limbus.

 Apex of the triangle is away from the cornea.
 It affects the nasal side first and then the temporal
side .
Complications
 inflammation,
 intraepithelial abscess
 Arjuna

एको यः शशरुधिरोपमस्तु बिन्दुः शुक्लस्थो भवति तमर्जुनं वदन्ति ||७||
Red colored dot or patch develops in shukla
mandala which is painless and red like blood
of rabbit.
SUBCONJUNCTIVAL
HAEMORRHAGE
 Ecchymosis

It may vary in extent from small petechial

hemorrhage to an extensive .
one spreading under the whole of the bulbar
conjunctiva and thus making the white sclera of the
eye invisible.
 Etiology
Trauma
 (i) local trauma to the conjunctiva including that due to
surgery and subconjunctival injections
 (ii) retrobulbar haemorrhage which almost immediately
spreads below the bulbar conjunctiva
Inflammations of the conjunctiva
Sudden venous congestion of head
 Rupture of conjunctival capillaries due to sudden rise in
pressure
 Common conditions are whooping cough, epileptic fits,
strangulation or compression of jugular veins and violent
compression of thorax and abdomen
Spontaneous rupture of fragile capillaries may occur
in vascular diseases such as arteriosclerosis,
hypertension and diabetes mellitus.
Local vascular anomalies like telengiectasia,
varicosities, aneurysm or angiomatous tumour.
Blood dyscrasias like anaemias, leukaemias and
dysproteinaemias.
Bleeding disorders like purpura, haemophilia
and scurvy.
Acute febrile systemic infections such as malaria,
typhoid, diphtheria, meningococcal septicaemia,
measles and scarlet fever.
Vicarious bleeding associated with menstruation
 Treatment

(i) Treat the cause when discovered.

(ii) Placebo therapy with astringent eye drops.
(iii) Psychotherapy and assurance to the patient is
most important part of treatment.
(iv) Cold compresses to check the bleeding in the
initial stage and hot compresses may help in
absorption of blood in late stages.
 Shuktika

श्यावाः स्युः पिशितनिभाश्च बिन्दवो ये शुक्त्याभाः सितनयने स शुक्तिसञ्ज्ञः |७|su
पित्तं कु र्यात्सिते बिन्दूनसितश्यावपीतकान्||१०||
मलाक्तादर्शतुल्यं वा सर्वं शुक्लं  सदाहरुक् |
रोगोऽयं शुक्तिकसंज्ञः सशकृ द्भेदतृड्ज्वरः||११||AH
Blackish whit patches or dots spread in
shukla mandala like shukti
Eye appears dirty as the mirror with dust
particles.
The patient has pain and burning sensation
in the eyes associated with diarrhea ,thirst,
and fever.
 Xerosis

Xerosis of the conjunctiva is a

symptomatic condition in which
conjunctiva becomes dry and
lustreless.
1. Parenchymatous xerosis
 Trachoma,
 Diptheric membranous
conjunctivitis,
 Steven-johnsons
syndrome,
 Pemphigus or pemphigoid
conjunctivitis,
 Thermal, chemical or
radiational burns of
conjunctiva
 Exposure of conjunctiva to air
 Marked degree of proptosis,
 Facial palsy
 Ectropion,
 Lack of blinking
 Lagophthalmos due to symblepharon.
2. Epithelial xerosis
 It occurs due to hypovitaminosis -A.
 Epithelial xerosis may be seen in association
with night blindness
 Epithelial xerosis typically occurs in children
and is characterized by varying degree of
conjunctival thickening, wrinkling and
pigmentatiion.