Scleromalacia Perforans Types and Complications

Scleromalacia perforans is a serious eye condition that can result in loss of vision. Scleromalacia perforans, also known as necrotizing scleritis, is the most severe form of scleritis, sometimes leading to loss of the eye. The condition is often associated with systemic disease and the involvement of multiple organs.

Scleromalacia perforans is characterized by severe thinning of the sclera of the eye and can be categorized into two types, with inflammation, and without inflammation. This type of scleritis is often associated with severe rheumatoid arthritis.

Also Known As: Necrotizing scleritis


Scleritis is an inflammation of the sclera, the white outer covering of the eye. Blood vessels travel through and on top of the sclera and can be involved in scleritis. Scleritis can be destructive to the eye, causing intense pain and loss of vision for some people. Although scleritis may be associated with trauma or infection, many times scleritis cases are associated with an underlying systemic disease such as rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, polyarteritis nodosa, granulomatosis with polyangiitis, herpes zoster virus, gout, and syphilis. These conditions cause general inflammation in the rest of the body.


Anterior scleritis, the most common type, affects the front portion of the sclera. There are three types of anterior scleritis:

  • Diffuse scleritis is the most common type and is easily treatable. This type displays general redness and inflammation in the front portion of the sclera.
  • Nodular scleritis has nodules or bumps which are often tender to the touch, on the surface of the eye.
  • Necrotizing scleritis (also called scleromalcia perforans) is the most severe form of anterior scleritis.

Posterior scleritis is the rarest form. It affects the back portion of the eye and often is not related to an underlying systemic disorder. This form can cause complications such as retinal detachment and angle-closure glaucoma.

Scleromalcia perforans accounts for only 4% of scleritis. People that suffer from scleromalcia perforans have severe pain. The pain can be much greater than what the eye actually appears.

Signs and Symptoms

  • redness
  • chemosis (conjunctival swelling)
  • eyelid swelling
  • proptosis (eye bulging outward)
  • decreased vision

Additionally, doctors may see:

  • choroidal folds
  • retinal elevation
  • optic disc swelling
  • macular swelling
  • retinal detachment


  • Vision loss
  • Large amounts of astigmatism
  • Anterior uveitis
  • Cataract
  • Glaucoma
  • Globe perforation

The most serious complication of scleromalcia perforans is the perforation of the globe of the eye. When this happens, you can actually see through the sclera, the white part of the eye, and see the tissue underneath. When this happens, a scleral graft will be surgically fastened to the sclera. The type of tissue used for the graft can be donor tissue. In this case, the patient may have to take drugs to suppress their immune system to prevent rejection of the tissue.

Medical treatment of the scleritis once it gets to this point is challenging. Many doctors will try steroids and non-steroidal anti-inflammatory drugs, but they do not seem to work very well. Special immuno-modulatory drugs have shown some promise.

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