- •The Sclera
- •Preface
- •Contents
- •1.1 Introduction
- •1.2 Development of the Sclera
- •1.2.1.1 First Week
- •1.2.1.2 Second Week
- •1.2.1.3 Third Week
- •1.2.1.4 Fourth Week
- •1.2.1.5 Fifth Week
- •1.2.1.6 Sixth Week
- •1.2.1.7 Seventh Week
- •1.2.1.8 Ninth Week
- •1.2.1.9 Tenth Week
- •1.2.1.10 Thirteenth Week
- •1.2.1.11 Sixteenth Week
- •1.2.1.12 Twenty-Fourth Week
- •1.2.2.1 Collagens
- •1.2.2.2 Proteoglycans
- •1.2.2.3 Glycoproteins
- •1.3 Anatomy
- •1.3.1 Gross and Microscopic Anatomy
- •1.3.1.1 Scleral Foramina
- •Anterior Scleral Foramen
- •Posterior Scleral Foramen
- •1.3.1.2 Layers of the Sclera
- •Episclera
- •Scleral Stroma
- •Lamina Fusca
- •1.3.1.3 Blood Supply and Emissary Canals
- •Vascular Distribution
- •Circulatory Dynamics
- •1.3.1.4 Nerve Supply
- •1.3.2 Ultramicroscopic Anatomy
- •1.3.2.1 Sclera
- •1.3.2.2 Vessels
- •1.4 Biochemistry
- •1.5 Immunohistochemistry
- •1.6 Biomechanics
- •1.7 Molecular Structure
- •1.7.1 Collagen
- •1.7.2 Elastin
- •1.7.3 Proteoglycans
- •1.7.4 Glycoproteins
- •1.7.6 Fibroblast Growth Regulation
- •1.8 Summary
- •References
- •2.1 General Immune Response Considerations
- •2.1.1 Components of the Adaptive Immune Response
- •2.1.1.1 Lymphocytes
- •T Lymphocytes
- •B Lymphocytes
- •Third-Population Lymphocytes or Null Lymphocytes
- •2.1.1.2 Monocytes/Macrophages
- •Phagocytosis
- •Antigen-Presenting Cells
- •2.1.1.3 Polymorphonuclear Granulocytes
- •Neutrophils
- •Eosinophils
- •Basophils/Mast Cells
- •2.1.1.4 Platelets
- •2.1.2 Immunoregulation
- •2.1.2.1 Major Histocompatibility Complex
- •2.1.2.2 Humoral Mechanisms: Antibodies
- •2.1.2.3 Cellular Mechanisms
- •2.1.2.4 Summary
- •2.1.3 Abnormalities of the Immune Response
- •2.1.3.1 Hypersensitivity Reactions
- •Type III Hypersensitivity Reactions
- •Systemic Immune Complex Disease
- •Local Immune Complex Disease (Arthus Reaction)
- •Type IV Hypersensitivity Reactions
- •2.1.3.2 Autoimmunity
- •Mechanisms of Autoimmunity
- •2.2 Connective Tissue and the Immune Response
- •2.2.1 Fibroblast Functions and the Immune Response
- •2.3 The Sclera and the Immune Response: Scleritis
- •2.3.1 Immune Characteristics of the Sclera
- •2.3.2 The Susceptible Host: Immunogenetics
- •2.3.3 Etiology
- •2.3.3.1 Exogenous Agents
- •Viruses
- •Mycobacteria
- •2.3.3.2 Endogenous Substances
- •Glycosaminoglycans
- •Collagen
- •2.3.4 Pathogenesis
- •2.4 Summary
- •References
- •3.1 Investigation of the Illness
- •3.1.1 Major Complaint and History of Present Illness
- •3.1.2 Past History
- •3.1.3 Family History
- •3.1.4 Past and Present Therapy History
- •3.1.5 Review of Systems
- •3.1.6 Systemic Examination
- •3.1.6.1 Head
- •3.1.6.2 Extremities
- •3.1.7 Ocular Examination
- •3.1.7.1 Episcleral and Scleral Examination
- •External Examination of the Eye in Daylight
- •Slit-Lamp Examination
- •Diffuse Illumination
- •Slit-Lamp Illumination
- •Red-Free Illumination
- •3.1.7.2 General Eye Examination
- •Visual Acuity
- •Pupils and Extraocular Muscles
- •Cornea
- •Anterior Uvea
- •Lens
- •Fundus
- •Intraocular Pressure
- •3.2 Diagnostic Tests
- •3.2.1 Blood Tests
- •3.2.1.1 Rheumatoid Factor
- •3.2.1.2 Anticyclic Citrullinated Peptide Antibodies
- •3.2.1.3 Antinuclear Antibodies
- •3.2.1.4 Antineutrophil Cytoplasmic Antibodies
- •3.2.1.5 Circulating Immune Complexes
- •Fluid-Phase Binding Assays
- •C1q-Binding Assay
- •Cell-Binding Assays
- •Raji Cell-Binding Assay
- •3.2.1.6 Complement
- •Quantitation Tests
- •Functional Tests
- •3.2.1.7 HLA Typing
- •3.2.1.8 Antibody Titers Against Infectious Organisms
- •3.2.1.9 Interferon-Gamma Release Assays (IGRAs)
- •3.2.2 Anterior Chamber Polymerase Chain Reaction Testing
- •3.2.3 Smears and Cultures
- •3.2.4 Skin Testing
- •3.2.5 Radiologic Studies
- •3.2.6.1 Anterior Segment Fluorescein Angiography Techniques
- •3.2.6.2 Normal Anterior Segment Fluorescein Angiography
- •Arterial Phase
- •Capillary Phase
- •Venous Phase
- •3.2.7 Anterior Segment Indocyanine Green Angiography
- •3.2.8 Other Imaging Studies
- •3.2.8.1 Ultrasonography
- •A-Scan Ultrasonography
- •B-Scan Ultrasonography
- •High-Frequency Ultrasound Biomicroscopy
- •3.2.8.2 Optical Coherence Tomography
- •3.2.8.3 Computer Tomography Scanning
- •3.2.8.4 Magnetic Resonance Imaging
- •3.3 Biopsy
- •3.3.1 Biopsy for Suspected Systemic Vasculitic Disease
- •3.4 Data Integration: Diagnosis
- •3.5 Therapeutic Plan
- •3.6 Summary
- •References
- •4.1 Episcleritis
- •4.1.1 Introduction
- •4.1.2 Patient Characteristics
- •4.1.3 Clinical Manifestations
- •4.1.4.1 Simple Episcleritis
- •4.1.4.2 Nodular Episcleritis
- •4.1.5 Associated Diseases
- •4.1.6 Precipitating Factors
- •4.2 Scleritis
- •4.2.1 Introduction
- •4.2.2 Patient Characteristics
- •4.2.3 Clinical Manifestations
- •4.2.4.1 Diffuse Anterior Scleritis
- •4.2.4.2 Nodular Anterior Scleritis
- •Differential Diagnosis
- •Paralimbic Scleromalacia
- •Senile Scleral Hyaline Plaques
- •4.2.4.5 Posterior Scleritis
- •Symptoms and Signs
- •Fundus Findings
- •Choroidal Folds
- •Subretinal Mass
- •Disk Edema and Macular Edema
- •Annular Ciliochoroidal Detachment and Serous Retinal Detachment
- •Associated Diseases
- •Complications
- •Ancillary Tests
- •Ultrasonography
- •Computerized Tomography (CT) Scanning
- •Fluorescein Angiography
- •Differential Diagnosis
- •Proptosis, Chemosis, Lid Swelling, and Limitation of Ocular Movements
- •Subretinal Mass
- •Choroidal Folds
- •Annular Ciliochoroidal Detachment and/or Serous Retinal Detachment
- •Disk and Macular Edema
- •4.2.5 Associated Diseases
- •4.2.6 Complications of Scleritis
- •4.2.6.1 Keratopathy
- •Peripheral Corneal Thinning
- •Stromal Keratitis
- •Peripheral Ulcerative Keratitis
- •4.2.6.2 Uveitis
- •4.2.6.3 Glaucoma
- •Angle-Closure Glaucoma
- •Open-Angle Glaucoma
- •Neovascular Glaucoma
- •4.2.6.4 Cataract
- •4.3 Summary
- •References
- •5: Pathology in Scleritis
- •5.1.3 Fibrinoid Necrosis
- •5.2.1 Pathology of Episcleritis
- •5.2.2 Pathology of Scleritis
- •5.2.2.1 Noninfectious Scleritis
- •Sclera
- •Cells
- •Extracellular Matrix
- •Vessels
- •Episclera
- •Conjunctiva
- •Iris, Ciliary Body, and Choroid
- •Cornea
- •Other Ocular Structures
- •Polyarteritis Nodosa
- •Allergic Granulomatous Angiitis (Churg–Strauss Syndrome)
- •Granulomatosis with Polyangiitis (Wegener)
- •Connective Tissue Diseases
- •Clinicopathological Correlates in Infectious Scleritis
- •Systemic Infections
- •Local Infections
- •5.3 Biopsy
- •5.3.1 Noninfectious Necrotizing Scleritis
- •5.3.2 Noninfectious Recurrent Diffuse or Nodular (Nonnecrotizing) Scleritis
- •5.3.3 Infectious Scleritis (Diffuse, Nodular, or Necrotizing Scleritis)
- •5.3.4 Biopsy Technique
- •5.4 Summary
- •References
- •6: Noninfectious Scleritis
- •6.1.1 Adult Rheumatoid Arthritis
- •6.1.1.1 Epidemiology
- •Signs and Symptoms of Joint Involvement
- •Extraarticular Systemic Manifestations
- •6.1.1.2 Systemic Manifestations
- •Onset
- •Tegument
- •Vessels
- •Lung
- •Heart
- •Nervous System
- •Lymph Nodes
- •Larynx
- •Felty’s Syndrome
- •Amyloidosis
- •Miscellaneous
- •6.1.1.3 Ocular Manifestations
- •Keratoconjunctivitis Sicca
- •Scleritis
- •Keratitis
- •Anterior Uveitis
- •Glaucoma
- •Cataract
- •Retinal, Choroidal, and Optic Nerve Changes
- •Motility Disturbances
- •Episcleritis
- •6.1.1.4 Laboratory Findings
- •Rheumatoid Factor
- •Antibodies to Cyclic Citrullinated Polypeptides
- •Complete Blood Count
- •Acute-Phase Reactants
- •Synovial Fluid Analysis
- •Circulating Immune Complexes
- •Antinuclear Antibodies
- •Complement
- •Cryoglobulins
- •Radiographic Evaluation
- •Diagnosis
- •6.1.2 Systemic Lupus Erythematosus
- •6.1.2.1 Epidemiology
- •6.1.2.2 Systemic Manifestations
- •Musculoskeletal
- •Tegument
- •Vessels
- •Kidney
- •Hearth
- •Nervous System
- •Lung
- •Miscellaneous
- •6.1.2.3 Ocular Involvement
- •Scleritis
- •Episcleritis
- •Other Ocular Findings
- •6.1.2.4 Laboratory Findings
- •6.1.2.5 Diagnosis
- •6.1.3 Ankylosing Spondylitis
- •6.1.3.1 Epidemiology
- •6.1.3.2 Systemic Manifestations
- •Articular Involvement
- •Extraarticular Systemic Manifestations
- •6.1.3.3 Ocular Manifestations
- •Anterior Uveitis
- •Scleritis
- •Episcleritis
- •6.1.3.5 Diagnosis
- •6.1.4 Reactive Arthritis (Reiter)
- •6.1.4.1 Epidemiology
- •6.1.4.2 Systemic Manifestations
- •Articular Involvement
- •Extraarticular Systemic Manifestations
- •6.1.4.3 Ocular Manifestations
- •Conjunctivitis
- •Anterior Uveitis
- •Scleritis
- •Episcleritis
- •Other Ocular Findings
- •6.1.4.4 Laboratory and Radiographic Findings
- •6.1.4.5 Diagnosis
- •6.1.5 Psoriatic Arthritis
- •6.1.5.1 Epidemiology
- •6.1.5.2 Systemic Manifestations
- •Skin and Articular Involvement
- •6.1.5.3 Ocular Manifestations
- •Scleritis
- •Episcleritis
- •6.1.5.4 Laboratory and Radiographic Findings
- •6.1.5.5 Diagnosis
- •6.1.6.1 Epidemiology
- •6.1.6.2 Systemic Manifestations
- •Gastrointestinal and Articular Manifestations
- •6.1.6.3 Ocular Manifestations
- •Anterior Uveitis
- •Scleritis
- •Episcleritis
- •Keratitis
- •6.1.6.4 Laboratory and Joint Radiologic Findings
- •6.1.6.5 Diagnosis
- •6.1.7 Relapsing Polychondritis
- •6.1.7.1 Epidemiology
- •6.1.7.2 Systemic Manifestations
- •6.1.7.3 Ocular Manifestations
- •Scleritis
- •Episcleritis
- •6.1.7.4 Laboratory Findings
- •6.1.7.5 Diagnosis
- •6.1.8 Polyarteritis Nodosa
- •6.1.8.1 Epidemiology
- •6.1.8.2 Systemic Manifestations
- •6.1.8.3 Ocular Manifestations
- •Scleritis
- •Episcleritis
- •6.1.8.4 Laboratory and Angiographic Findings
- •6.1.8.5 Diagnosis
- •6.1.9.1 Epidemiology
- •6.1.9.2 Systemic Manifestations
- •6.1.9.3 Ocular Manifestations
- •6.1.9.4 Laboratory Findings
- •6.1.9.5 Diagnosis
- •6.1.10 Granulomatosis with Polyangiitis (Wegener)
- •6.1.10.1 Epidemiology
- •6.1.10.2 Clinical Manifestations
- •6.1.10.3 Ocular Manifestations
- •Scleritis
- •Episcleritis
- •6.1.10.4 Laboratory Findings
- •6.1.10.5 Diagnosis
- •6.1.11 Adamantiades–Behçet’s Disease
- •6.1.11.1 Epidemiology
- •6.1.11.2 Systemic Manifestations
- •6.1.11.3 Ocular Manifestations
- •Scleritis
- •Episcleritis
- •6.1.11.4 Laboratory Findings
- •6.1.11.5 Diagnosis
- •6.1.12 Giant-Cell Arteritis
- •6.1.12.1 Epidemiology
- •6.1.12.2 Systemic Manifestations
- •6.1.12.3 Ocular Manifestations
- •Scleritis
- •6.1.12.4 Laboratory Findings
- •6.1.12.5 Diagnosis
- •6.1.13 Cogan’s Syndrome
- •6.1.13.1 Clinical Manifestations
- •Scleritis
- •Episcleritis
- •6.1.13.2 Laboratory Findings
- •6.2.1 Rosacea
- •6.3.1 Gout
- •6.5 Chemical Injury-Associated Scleritis
- •6.6 Summary
- •References
- •7: Infectious Scleritis
- •7.1 Bacterial Scleritis
- •7.1.1.1 Pathogenesis
- •7.1.1.2 Organisms
- •7.1.1.3 Management
- •7.1.1.4 Therapy
- •7.1.1.5 Prognosis
- •7.1.1.6 Our Experience
- •7.1.2 Mycobacterial Scleritis
- •7.1.2.1 Atypical Mycobacterial Disease
- •7.1.2.2 Tuberculosis
- •7.1.2.3 Leprosy
- •7.1.3 Spirochetal Scleritis
- •7.1.3.1 Syphilis
- •Epidemiology
- •Pathogenesis and Clinical Features
- •Scleritis and Episcleritis
- •Diagnosis
- •Therapy
- •7.1.3.2 Lyme Disease
- •Epidemiology
- •Pathogenesis and Clinical Features
- •Scleritis and Episcleritis
- •Diagnosis
- •7.1.3.3 Treatment
- •7.1.4 Chlamydial Scleritis
- •7.1.5 Actinomycetic Scleritis
- •7.1.5.1 Nocardiosis
- •7.2 Fungal Scleritis
- •7.2.1 Filamentous and Dimorphic Fungal Scleritis
- •7.2.1.1 Pathogenesis
- •7.2.1.2 Organisms
- •7.2.1.3 Management
- •7.2.1.4 Therapy
- •7.2.1.5 Our Experience
- •7.3 Viral Scleritis
- •7.3.1 Herpes Scleritis
- •7.3.1.1 Herpes Zoster Scleritis
- •Epidemiology
- •Pathogenesis
- •Clinical Features
- •Scleritis
- •Episcleritis
- •Diagnosis
- •Treatment
- •7.3.1.2 Herpes Simplex Scleritis
- •Epidemiology
- •Pathogenesis
- •Clinical Features
- •Scleritis
- •Episcleritis
- •Diagnosis
- •Therapy
- •Our Experience
- •7.3.2 Mumps Scleritis
- •7.4 Parasitic Scleritis
- •7.4.1 Protozoal Scleritis
- •7.4.1.1 Acanthamoeba
- •7.4.1.2 Toxoplasmosis
- •7.4.2 Helminthic Scleritis
- •7.4.2.1 Toxocariasis
- •7.5 Summary
- •References
- •8.1 Scleral Deposits
- •8.1.1 Scleral Protein Deposition
- •8.1.1.1 Porphyria
- •8.1.1.2 Cystinosis
- •8.1.1.3 Alkaptonuria
- •8.1.1.4 Amyloidosis
- •8.1.2 Scleral Lipid Deposition
- •8.1.2.1 Familial Hypercholesterolemia and Histiocytosis X
- •8.1.2.2 Age-Related Degeneration
- •8.1.3 Scleral Carbohydrate Deposition
- •8.1.3.1 Mucopolysaccharidosis
- •8.1.4 Scleral Mineral Deposition: Calcium
- •8.1.4.1 Hyperparathyroidism
- •8.1.4.2 Other Causes of Hypercalcemia
- •8.1.4.3 Age-Related Degeneration
- •Senile Scleral Hyaline Plaques
- •8.1.5 Scleral Pigment Deposition: Bilirubin
- •8.1.5.1 Jaundice
- •8.2 Scleral Thinning (Blue Sclerae)
- •8.2.1 Scleral Thinning in Inherited or Congenital Diseases
- •8.2.1.1 Marfan’s Syndrome
- •8.2.1.2 Osteogenesis Imperfecta
- •8.2.1.3 Pseudoxanthoma Elasticum
- •8.2.1.4 Ehlers–Danlos Syndrome
- •8.2.1.5 Keratoconus
- •8.2.1.6 Buphthalmos
- •8.2.1.7 Coloboma
- •8.2.1.8 Myopia
- •8.2.2 Scleral Thinning in Acquired Diseases
- •8.2.2.2 Paralimbal Scleromalacia
- •8.3 Scleral Thickening
- •8.3.1 Nanophthalmos
- •8.3.2 Scleropachynsis
- •8.3.3 Phthisis Bulbi
- •8.4 Scleral Tumors
- •8.4.1 Dermoid Choristomas
- •8.4.2 Epithelial Tumors
- •8.4.2.1 Papillomas or Intraepithelial Epitheliomas
- •8.4.2.2 Squamous Cell Carcinoma
- •8.4.3 Dense Connective Tissue Tumors
- •8.4.3.1 Nodular Fasciitis
- •8.4.3.2 Fibroma
- •8.4.3.3 Fibrous Histiocytoma
- •8.4.3.4 Sarcomas
- •8.4.4 Vascular Tumors
- •8.4.4.1 Hemangiomas
- •8.4.4.2 Lymphangiomas
- •8.4.5 Blood Cell Tumors
- •8.4.5.1 Leukemia
- •8.4.5.2 Lymphoma and Lymphosarcoma
- •8.4.6 Nervous Tumors
- •8.4.6.2 Neurilemmoma (Schwannoma)
- •8.4.7 Pigmented Tumors
- •8.4.7.1 Nevus
- •8.4.7.2 Melanocytoma
- •8.4.8 Secondary Tumors
- •8.5 Summary
- •References
- •9.1 Treatment of Episcleritis
- •9.2 Treatment of Scleritis
- •9.2.1 Medical Treatment
- •9.2.1.1 Rheumatoid Arthritis
- •9.2.1.2 Systemic Lupus Erythematosus
- •9.2.1.3 Polyarteritis Nodosa
- •9.2.1.4 Granulomatosis with Polyangiitis (Wegener)
- •9.2.1.5 Relapsing Polychondritis
- •9.2.1.7 Posterior Scleritis
- •9.2.1.8 Infectious Scleritis
- •9.2.2 Ancillary Therapy
- •9.2.3 Drug Management Responsibility
- •9.2.4 Surgical Treatment
- •9.3 Summary
- •References
- •Index
36 |
2 Immunologic Considerations of the Sclera |
|
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cell-mediated cytotoxicity (ADCC) reaction. They also are involved in the removal of cellular antigens when the target cell is too large to be phagocytized.
2.1.1.2 Monocytes/Macrophages
Bone marrow-derived stem cells give rise to promonocytes, which subsequently differentiate into blood monocytes. Blood monocytes migrate into tissues to become macrophages. Aside from class II MHC glycoprotein on their cell surfaces (HLA-DR), monocytes/macrophages possess receptors for complement components, including CR1 (CD35) and CR3 (CD11b), as well as for the Fc portion of immunoglobulin G molecules (CD16), Þbronectin, interferons (a, b, and g), IL-1, tumor necrosis factor, and macrophage col- ony-stimulating factor. Monocytes/macrophages may be subdivided depending on two different functions, that is, phagocytosis and antigen presentation to lymphocytes.
Phagocytosis
The human blood monocyte possesses a horseshoe-shaped nucleus with faint azurophilic granules, rufßed membrane, a well-developed Golgi complex, and many intracytoplasmic lysosomes. Monocytes/macrophages are members of the natural immune system and they play a central role in host defense through phagocytosis. The phagocytic macrophages form a network, the reticuloendothelial system, found in many organs of the body. The reticuloendothelial system includes Kupffer cells in the liver, intraglomerular mesangial cells in the kidney, alveolar macrophages in the lung, microglial cells in the brain, spleen sinus cells, and lymph node sinus cells.
However, monocytes/macrophages can also participate in abnormal reactions. They can be attracted by complement components in type III hypersensitivity or immune complex-mediated diseases; furthermore, they can participate in granuloma formation as epithelioid cells (modiÞed macrophages) or multinucleated giant cells (fusion of several epitheloid cells) in type IV hypersensitivity or cell-mediated diseases.
Table 2.2 Secretory products of macrophagesa
Enzymes
Lysozyme Neutral proteases
(collagenase and elastase) Acid proteases (cathepsins) Acid lipases
Acid nucleases Acid phosphatases Acid glycosidases Acid sulfatases Arginase
Plasminogen activator Lipoprotein lipase Phospholipase A2 Cytolytic proteinase Angiotensin convertase
Inhibitors of enzymes a2−Macroglobulin a1-Antiprotease Lipocortin a1-Antichymotrypsin
Reactive oxygen intermediates
O2, H2O2, OH, hypohalous acids
Lipids
PGE2b
PGF2ab Prostacyclin
Tromboxane A2 Leukotrienes B, C, D, and E Mono-HETESb
Di-HETES Platelet-activating factor
Coagulation factors
Factors X, IX, VII, V Protein kinase Thromboplastin Prothrombin Fibrinolysis inhibitor
Components of complement cascade
C1, C4, C2, C3, C5 Factors B and D Properdin
C3b inactivator b IH
Other proteins
Transcobalamin II Transferrin Fibronectin Interferons a and b
Tumor necrosis factor a Interleukins 1 and 6 Macrophage colonystimulating factor Granulocyte-macrophage colony-stimulating factor Haptoglobin Platelet-derived growth factor
Transforming growth factor b Erythropoietin Thymosin B4 Apolipoprotein E Serum amyloid A Serum amyloid P
Small molecules
Purines
Pyrimidines
aAdapted from references [21Ð23]
bPGE2 prostaglandin E2, PGF2a prostaglandin F2a, HETES hydroxyeicosatetraenoic acids
Monocytes/macrophages secrete a variety of powerful biological molecules that are important (Table 2.2) [21Ð23]. Among these molecules, the enzymes, collagenase and elastase, participate in connective tissue degradation.
Antigen-Presenting Cells
Macrophages are the preeminent antigenpresenting cells. They phagocytose the antigen, partially degrade it, and transport the fragments