Scleritis

SCLERITIS (scleritis), inflammation of the sclera as a particular disease of the eye was identified by Arlt (F. Arlt, 1853), who also determined its main characteristics. The disease is not common, according to Goldzieher, one case per 300 eye patients, and does not always follow the same course. A distinction is made between the deep form, or proper S, and the superficial form-episcleritis. The deep form of S. is observed predominantly in young age (20-30 years) and more often in women than in men. The disease is localized in the anterior part of the sclera between the edge of the cornea and the equator, usually closer to the limbus. In some area of this region, hyperemia appears, and then a nodule about 5 mm in diameter forms, protruding little above the surface of the sclera, but sharply noticeable for its purple-violet color and sensitivity to pressure. The surrounding conjunctiva is hyperemic, above the inflammatory focus it is easily movable, but the nodule itself is not movable. The formed focus persists for many weeks, sometimes even months, then its color begins to fade, sensitivity decreases and the inflammation gradually passes, but in its place remains a thinning of the sclera, noticeable by a grayish or grayish-blue coloration. Such an inflammatory focus very rarely remains solitary; usually at some distance from the first nodule a second one appears, then another and so the process can gradually spread around the entire edge of the cornea. In the progressive period, the disease is accompanied to a greater or lesser degree by pain, sometimes quite significant, tearing, general hyperemia of the entire conjunctiva of the sclera. Not infrequently, the inflammatory process spreads to the cornea in the form of sclerosing keratitis (see Keratitis), as well as to the iris and ciliary body. In pronounced cases, the deep form of S. has a very prolonged course; the pathological process, now subsiding now again exacerbating, can drag on for many years. Directly in the sclera, the transferred S. leaves characteristic signs in the form of slate spots or a general bluish discoloration of the entire pericorneal band depending on the transmission of the pigment of the ciliary body through the thinned tissue of the fibrous membrane. In addition, the affected area of the sclera becomes more yielding to intraocular pressure, as a result of which it often undergoes stretching with the formation of an iridociliary or ciliary staphyloma (see Sclera). The accompanying inflammation of the anterior part of the uvea, causing the appearance of posterior synechiae, in a number of cases leads to an increase in intraocular pressure; secondary glaucoma is formed with its serious consequences for the eye. At the same time, vision in the affected eye often suffers from clouding of the cornea due to sclerosing keratitis or from the deposition and subsequent organization of exudate on the surface of the lens as a result of accompanying iridocyclitis. Thus, S. in its deep form, both in course and outcome, represents a very serious eye disease, often leading to significant impairment of vision, sometimes complete blindness. The prognosis is all the more unfavorable that both eyes almost always become affected. Particularly severe cases of S. with multiple deep infiltrates of the sclera, involvement of the anterior part of the uvea and a very malignant course have recently been distinguished by Szily (v. Szily) as a separate form under the name sclero-perikeratitis progressiva. The superficial S., or episcleritis, presents a different picture. This form usually occurs in old age. In the pericorneal area, a limited inflammatory focus with a characteristic violet shade forms, noticeably protruding above the surface of S, dense to the touch and painful on pressure. The connective membrane is not fused with the focus and is hyperemic only in the area of the inflammatory swelling. The episcleritic nodule remains for several weeks, showing no signs of disintegration or ulceration, and then slowly resolves. The appearance of the nodule is often accompanied by significant pain, continuing to some degree in the further course until the disappearance of the inflammatory focus, after which the eye returns to "completely normal condition." In typical cases, the disease thus does not take a prolonged character, but there is a tendency to recurrences even with this form. Attacks can recur at intervals of several months to several years, and with each attack the inflammatory focus forms in a new area of the sclera. It is especially important that superficial S. is not complicated by inflammation of the cornea and uvea, does not lead to thinning of the sclera and formation of staphyloma, as a result of which vision does not suffer as a result of the disease.-Under the name episcleritis periodica fugax, Fuchs described peculiar, extremely frequently recurring attacks of episcleritis, lasting only several days, accompanied by rather diffuse hyperemia and edematous swelling of the conjunctiva, sometimes significant pain. The disease is rare in middle-aged persons and is noted for a very stubborn course. It is very rarely possible to examine the pathologically-anatomically eye affected by S.; in the ophthalmological literature, such studies have been published extremely few. The changes found consist of small-cell infiltration, pushing apart the bundles of scleral fibers and especially abundant in the deep layers of the sclera, as well as necrosis of the fibers themselves. It is characteristic that corresponding to the clinical picture, the changes are almost always limited to the anterior part of the sclera, spreading backward at most to the equator. Only in isolated cases as an accidental finding was pathologically-anatomical inflammatory lesion observed in the posterior part of the sclera (scleritis posterior). In the superficial form, the infiltration is localized mainly in the episclera, where in addition significant expansion of blood and lymphatic vessels has been established, giving the tissue a cavernous character. The etiology and pathogenesis of S. are not fully clarified. Superficial S. in elderly people apparently often stands in connection with rheumatism; Fuchs calls it episcleritis rheumatica. Gout is also considered its cause, often it remains unexplained. As for the deep form, there are many reasons to recognize the tuberculous nature of this disease. The studies of Stock are very convincing in this respect, who in rabbits after the introduction of tubercle bacilli into the blood obtained inflammatory foci not only in the uvea but also in the anterior segment of the sclera, as well as phenomena of sclerosing keratitis. Clinical data also speak for the predominant importance of tbc in the etiology of S. According to Knobloch, out of 63 patients suffering from S., tbc was clinically found in 79.3%, syphilis, rheumatism and staphylococcal infection were found separately in 3.6% and 11% etiology was not clarified. Regarding pathogenesis, it has not been finally established whether in the deep form the lesion of the sclera develops primarily or is preceded by an inflammatory process in the uvea. The experimental studies of Stock rather indicate the secondary nature of the scleral lesion. Treatment in S. is general and local. Salicylic preparations, sweating treatment have long been in use, recently protein therapy. According to the presumed etiology, specific general treatment is undertaken, in particular tuberculin therapy. Local treatment consists mainly in the application of heat (compresses, fomentations, hot-water bottles). Relief of pain and inflammatory phenomena is often obtained from the instillation of dionin (5-10%). Merkulova from the clinic of Prof. Samoilov reports good results from injections of adrenaline (1:1,000, dose 0.1 - 0.2, eight injections every two days). In case of complications with iritis and its consequences- appropriate therapy, sometimes surgical intervention.

3. Frapn-Kamenedky.