Scleromalacia perforans
 

scleromalacia perforans under the upper lid thinning of the sclera in a patient with recurrent scleritis. Note: the patient also has trabeculectomy.

. This condition is seen mainly in women with rheumatoid arthritis. The eye may be tender and you need to elevate the lid gently. There is exposure of the underlying dark uveal tissue (usually covered by the upper lid) with thinning of the surrounding sclera. The uvea is covered by thin connective tissue and conjunctiva. There are large abnormal blood vessels crossing areas of scleral loss. This condition is caused by necrotizing scleritis without inflammation and is seen in patients with long-standing rheumatoid arthritis. Look for: signs of rheumatoid arthritis such as symmetrical deformities of the hand joints occasionally this condition is seen in Wegener's granulomatosis and relapsing polychondritis. In these conditions, there may be saddle-nose due to cartilage destruction. In addition, relapsing polychondritis is associated with deformed ear.

Questions:

1. What types of scleritis do you know of?

Answer
Anterior scleritis
diffuse scleritis (most benign and 30% has an underlying connective tissue disease)
nodular scleritis (deep red to purple colour, immobile nodule)
necrotizing scleritis (the most destructive form, 60% of affected patients develop ocular and systemic complications, 40%suffer from loss of vision and 29% die within 5 years of onset due to complications from vasculitis). There are two types of necrotizing scleritis:
a. with inflammation
b. without inflammation
Posterior scleritis (least common, present with pain, protosis, visual loss and restricted motility. Choroidal folds, exudative retinal detachment, papilloedema, and angle-closure glaucoma from choroidal effusion can be found)

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