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RED EYE WITH NORMAL VISION


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Scleritis


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Definitiony Diffuse or localized inflammation of the sclera. Scleritis is

classified according to location:

y Anterior (inflammation anterior to the equator of the globe).

y Posterior (inflammation posterior to the equator of the globe).

y Anterior scleritis is further classified according to its nature:y Non-necrotizing anterior scleritis (nodular or diffuse).

y Necrotizing anterior scleritis (with or without inflammation).


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Epidemiology

y Patients are generally older, and women are affected more

often than men.


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Etiology

y Approximately 50% of scleritis cases (which tend to have

severe clinical courses) are attributable to systemic

autoimmune or rheumatic disease, or are the result of

immunologic processes associated with infection.

y This applies especially to anterior scleritis.

y Posterior scleritis is not usually associated with any specific

disorder. Scleritis is only occasionally due to bacterial or viral

inflammation.


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Symptoms and findings

y All forms except for scleromalacia perforans are associated

with severe pain and general reddening of the eye.

y Anterior non-necrotizing scleritis (nodular form). The nodules

consist of edematous swollen sclera and are not mobile (in

contrast to episcleritis).

y Anterior necrotizing scleritis (diffuse form). The inflammation

is more severe than in the nodular form. It can be limited to a

certain segment or may include the entire anterior sclera.


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y Anterior necrotizing scleritis with inflammation. Circumscribed

reddening of the eyes is a typical sign. There may be deviation or

injection of the blood vessels of the affected region,

accompanied by avascular patches in the episcleral tissue. As the

disorder progresses, the sclera thins as the scleral lamellae ofcollagen fibrils melt, so that the underlying choroid shows

through. The inflammation gradually spreads from its primary

focus. Usually it is associated with uveitis.


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y Anterior necrotizing scleritis without inflammation

(scleromalacia perforans). This form of scleritis typically occurs

in female patients with a long history of seropositive

rheumatoid arthritis. The clinical course of the disorder is

usually asymptomatic and begins with a yellownecrotic patch onthe sclera. As the disorder progresses, the sclera also thins so

that the underlying choroid shows through. This is the only

form of scleritis that may be painless.


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y Posterior scleritis. Sometimes there will be no abnormal

findings in the anterior eye, and pain will be the only

symptom. Associated inflammation of the orbit may result in

proptosis (exophthalmos) and impaired ocular motility due

to myositis of the ocular muscles. Intraocular findings may

include exudative retinal detachment and/or choroid

detachment. Macular and optic disk edema are frequently

present.


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Differential diagnosis

y Conjunctivitis and episcleritis


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Treatmenty Anterior non-necrotizing scleritis. Topical or systemic

nonsteroidal antiinflammatory therapy.

y Anterior necrotizing scleritis with inflammation. Systemic steroidtherapy is usually required to control pain. If corticosteroids donot help or are not tolerated, immunosuppressive agents may beused.

y Anterior necrotizing scleritis without inflammation (scleromalaciaperforans).

y As no effective treatment is available, grafts of preserved sclera orlyophilized dura may be required to preserve the globe if the

course of the disorder is fulminant.y Posterior scleritis. Treatment is the same as for anterior

necrotizing scleritis with inflammation.


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pterygium


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Definition

y Triangular fold of conjunctiva that usually grows from the

medial portion of the palpebral fissure toward the cornea.


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Epidemiology

y Pterygium is especially prevalent in southern countries due

to increased exposure to intense sunlight.


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Etiology

y Histologically, a pterygium is identical to a pinguecula.

However, it differs in that it can grow on to the cornea; the

gray head of the pterygium will grow gradually toward the

center of the cornea. This progression is presumably the

result of a disorder of Bowmans layer of the cornea, which

provides the necessary growth substrate for the pterygium.


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Symptoms and diagnostic

considerations

y A pterygium only produces symptoms when its head

threatens the center of the cornea and with it the visual axis.

Tensile forces acting on the cornea can cause severe corneal

astigmatism. A steadily advancing pterygium that includes

scarred conjunctival tissue can also gradually impair ocular

motility; the patient will then experience double vision in

abduction.


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Treatment

y Treatment is only necessary when the pterygium produces

the symptoms discussed above. Surgical removal is indicated

in such cases. The head and body of the pterygium are largely

removed, and the sclera is left open at the site. The cornea is

then smoothed with a diamond reamer or an excimer laser (a

special laser that operates in the ultraviolet range at a

wavelength of 193 nm).


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Clinical course and prognosis

y Pterygia tend to recur. Keratoplasty is indicated in such cases

to replace the diseased Bowmans layer with normal tissue.

Otherwise the diseased Bowmans layer will continue to

provide a growth substrate for a recurrent pterygium.


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Subconjunctival Hemorrhage


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y Extensive bleeding under the conjunctiva frequently occurs

with conjunctival injuries

y Subconjunctival hemorrhaging will also often occur

spontaneously in elderly patients (as a result of compromisedvascular structures in arteriosclerosis), or it may occur after

coughing, sneezing, pressing, bending over, or lifting heavy

objects.


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y Although these findings are often very unsettling for the

patient, they are usually harmless and resolve spontaneously

within two weeks. The patients blood pressure and

coagulation status need only be checked to exclude

hypertension or coagulation disorders when subconjunctival

hemorrhaging occurs repeatedly.


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Thank you

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