_ANATOMY OF THE SCLERA_

sclera is also referred to colloquially as the white of the eye, however, the term sclera is most commonly
used as it is the scientific name for this part of the eye’s anatomy.

What is the Structure of the Sclera?

The sclera is the white part of the eye that has a structure made of up four layers which are the
episclera, stroma, lamina fusca and endothelium. According to an article published in the National
Library of Medicine titled, Scleral structure and biomechanics, the sclera forms approximately 85% of
the outer tunic of the eyeball.

A demonstration of the structure of the sclera including the layers.

What is the Sclera Made of?

The sclera is made mainly of type 1 collagen fibres according to an article published in the National
Library of Medicine. The sclera is dense connective tissue and is white due to the lack of parallel
orientation of collagen fibres. Collagen is a type of protein found in the body and provides strength and
support for a person’s bones, skin, connective tissues and muscles.

What are the Layers of Sclera?

The sclera comprises four layers which are the episclera, stroma, lamina fusca and endothelium. The
layers of the sclera and their definitions are listed below.

Episclera: The episclera is the first, outermost layer of the sclera made of clear, thin tissue. The episclera
is connected to the Tenon capsule.

Stroma: The sclera is continuous with the stroma layer of the cornea. It is made of collagen fibres and
fibroblasts, according to the Cleveland Clinic.

Lamina fusca: The lamina fusca is a transitional layer between the sclera and the iris, choroid and other
parts of the eye.

Endothelium: The endothelium is the innermost layer of the sclera and is also a layer of the cornea
which is a very thin cell layer.
Where is the Sclera Located in the Anatomy of the Eye?

The sclera is the visible white of the eye located on the outside of the eye. In the anatomy of the eye,
the sclera is covered by the conjunctiva and is1 continuous from the cornea, extending from the cornea
to the optic nerve.

_FUNCTIONS OF THE SCLERA_

*I. Protective Functions*

1. Shields the eye from external damage, trauma, and infections.

2. Provides a barrier against foreign particles, bacteria, and other pathogens.

3. Protects the delicate internal structures of the eye.

*II. Structural Support*

1. Maintains the eye's shape and integrity.

2. Provides a framework for the attachment of extraocular muscles.

3. Supports the cornea, iris, and lens.

*III. Optical Functions*

1. Refractive Surface: Helps focus light by providing a smooth, curved surface.

2. Aqueous Humor Drainage: Facilitates drainage through the trabecular meshwork.

3. Maintains the eye's optical axis.

*IV. Nutritional and Immune Functions*

1. Blood Supply: Contains blood vessels supplying oxygen and nutrients.

2. Immune Response: Participates in protecting the eye from infection.

3. Provides passage for immune cells to reach the eye.

*V. Mechanical Functions*

1. Pressure Regulation: Helps regulate intraocular pressure.

2. Eye Movement: Provides anchor points for extraocular muscles.

3. Maintains the eye's position and alignment.

*VI. Barrier Function*

1. Prevents external substances from entering the eye.

2. Regulates the passage of substances through the sclera.

*VII. Support for Adjacent Tissues*

1. Provides structural support for surrounding tissues (e.g., eyelids, orbit).

2. Maintains the integrity of adjacent tissues.

*VIII. Attachment Site*

1. Provides attachment points for extraocular muscles.

2. Supports the insertion of tendons and ligaments.

*IX. Regulates Intraocular Pressure*

1. Helps maintain a stable intraocular pressure.

2. Regulates the flow of aqueous humor.

The sclera plays a vital role in maintaining the eye's integrity, protecting it from harm, and facilitating
various optical and physiological processes

_DEVELOPMENT AND GROWTH OF THE SCLERA_

The sclera, commonly referred to as the "white of the eye," is a dense, fibrous connective tissue that
forms the protective outer layer of the eyeball. Its development and growth are crucial for the structural
integrity and function of the eye. Here is an overview:

Embryonic Development

1. Origin:

- The sclera primarily arises from the neural crest mesenchyme, with minor contributions from
mesodermal cells.

- Development begins in the fourth to fifth week of gestation, following the formation of the optic cup.

2. Initial Formation:

- Scleral development starts anteriorly near the cornea and progresses posteriorly towards the optic
nerve.

- By the seventh week, the rudimentary scleral structure surrounds the eye.
3. Layer Formation:

- The sclera differentiates into three layers:

- Episclera: The outermost vascular layer.

- Scleral Stroma: The thick, collagenous middle layer.

- Lamina Fusca: The innermost pigmented layer adjacent to the choroid.

4. Fibre Arrangement:

- Collagen fibrils begin to align during development, providing tensile strength and elasticity. This
alignment is key for the eye's shape and durability.

Postnatal Growth

1. Rapid Growth in Infancy:

- After birth, the sclera undergoes rapid growth, especially in the first two years of life.

- During this period, the sclera is thinner and more pliable due to incomplete collagen cross-linking,
which gives infants' eyes a bluish tint.

2. Adolescence:

- Growth slows but continues to adjust to the increasing axial length of the eye.

- The sclera becomes more rigid and opaque as collagen fibres mature and thicken.

3. Adulthood:

- By adulthood, the sclera reaches its full thickness (approximately 0.3 mm at the equator and up to
1.0 mm at the posterior pole).

- It maintains its strength and shape, which is critical for accommodating the intraocular pressure and
maintaining the eye's structural integrity.
Factors Influencing Scleral Growth

1. Genetic Factors:

- Genetic predisposition plays a significant role in determining the size, shape, and rigidity of the sclera.

2. Environmental Factors:

- Prolonged near work and lack of outdoor activity have been associated with scleral remodelling and
elongation, contributing to conditions like myopia.

- Scleral thinning and stretching are common in high myopia, affecting eye function.

3. Hormonal Influences:

- Growth factors such as transforming growth factor-beta (TGF-β) and matrix metalloproteinases
(MMPs) regulate scleral remodelling during growth and in response to visual stimuli.

4. Pathological Conditions:

- Diseases like scleritis or Ehlers-Danlos syndrome can alter scleral composition and strength, leading
to thinning or weakness.

Aging Changes

In older adults, the sclera may become more brittle due to reduced collagen elasticity and hydration.

This increased rigidity contributes to the yellowish appearance seen in aged sclera due to fatty deposits
and calcification.
_DISEASES AND DISORDERS OF THE SCLERA_

1. Episcleritis

Episcleritis is a benign, self-limiting inflammation of the episclera, the thin vascular layer overlying the
sclera.

• Etiology: Often idiopathic but may be associated with systemic conditions like
rheumatoid arthritis or lupus.

• Symptoms: Mild discomfort, localized redness, and occasional tearing without

discharge.

• Management: Typically resolves without treatment, but artificial tears and topical anti-
inflammatory drops may be used for symptom relief.

2. Scleritis

Unlike episcleritis, scleritis is a severe, painful inflammation of the scleral tissue that can threaten vision.

• Etiology: Commonly linked to systemic autoimmune diseases such as Wegener’s

granulomatosis or rheumatoid arthritis.

• Symptoms: Intense pain radiating to the forehead or jaw, redness, photophobia, and
decreased vision.

• Types:

• Anterior Scleritis: The most common type, visible on the scleral surface.

• Posterior Scleritis: Less common but more dangerous, as it can cause retinal detachment
or optic nerve damage.

• Management: Requires systemic corticosteroids or immunosuppressive therapy. Urgent

referral to an ophthalmologist is critical.
3. Scleral Thinning and Ectasia

Conditions like scleral staphyloma and blue sclera result from thinning of the sclera.

• Blue Sclera:

• Associated with genetic conditions such as osteogenesis imperfecta or Ehlers-Danlos

syndrome.

• The underlying uveal tissue becomes visible, giving the sclera a bluish appearance.

• Staphyloma:

• Localized outpouching of the sclera due to increased intraocular pressure, often seen in
severe myopia or trauma.

• Requires surgical correction if vision is affected.

4. Infectious Scleritis

This rare but serious condition results from bacterial, fungal, or parasitic infections.

• Etiology: Often follows trauma, surgery, or contact lens misuse.

• Causative Agents: Common pathogens include Pseudomonas aeruginosa and Aspergillus

species.

• Symptoms: Severe pain, redness, and purulent discharge.

• Management: Requires aggressive antimicrobial therapy and sometimes surgical

intervention.

5. Scleral Icterus

Scleral icterus is not a primary scleral disease but a systemic indicator of jaundice due to elevated
bilirubin levels.

. Clinical significance: it often signals underlying hepatic or hematological disorders

 .Role of optometrist : Early detection can prompt timely referral for systemic evaluation

Diseases of the sclera often have systemic implications, making their diagnosis and management
multifaceted:

• Autoimmune Links: Conditions like lupus or rheumatoid arthritis can manifest as

episcleritis or scleritis, necessitating coordination with rheumatologists.

• Infectious Causes: A history of recent surgery or trauma may guide the optometrist
toward infectious scleritis.

• Imaging and Diagnostic Tools:

• Anterior Segment OCT: For detailed visualization of scleral layers.

• Ultrasound B-Scan: Useful in detecting posterior scleritis