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This Caucasian female has no complaints and presents for her yearly eye exam. Best corrected visual acuity is 20/20 in each eye. She has a non-inflamed eye with the gray translucent areas seen in the images. She first noticed the lesions after her cataract extraction which was performed in 2006. The lesions have remained stable in size and have never bothered her.

1.	The gray translucent areas are located in the:
	b -- sclera The slit-beam images show that the lesions are flat and at the level of the sclera.  The conjunctival and episcleral vessels are anterior to the lesions thus indicating that the lesions are deep to these structures.  Intraocular pressure would bulge the uvea anteriorly. Retina would be depressed into the globe.
2.	The gray translucent areas are associated with the:
	a -- insertion of the horizontal recti These sharply demarcated lesions are located just anterior to the insertions of the medial rectus muscles.  The horizontal muscle fibers can be seen just posterior to the lesions. The sharply demarcated borders and the flat nature of the lesions point away from melanoma of the uvea or conjunctiva which would likely have irregular borders and be elevated.  The lesions are not associated with post inflammatory thinning of the sclera. The patient has had no ocular inflammation and symptoms of scleritis. The slit-beam images show no scleral thinning which would not be sharply demarcated and would be associated with bulging uvea.
3.	The diagnosis is:
	d -- scleral plaque Scleral plaques or senile scleral plaques are characterized by sharply demarcated, slate-grey, translucent areas located just anterior to the insertions of the horizontal rectus muscles, most commonly the medial rectus.  The location is thought to be secondary to the constant stress and strain on the scleral fibers by the horizontal rectus muscles.  The transparency of the lesions is thought, in part, to be secondary to local dehydration of the sclera.  The plaques have been demonstrated by both histo-chemical methods and energy dispersive x-ray microanalysis to contain calcium phosphate.  These are not preceded or accompanied by inflammatory symptoms.   If this were scleritis, inflammation, scleral edema, and enlarged scleral vessels would be present.  Malignant melanoma would have irregular borders and be slightly raised instead of flat.  Post-scleritis sclera thinning, would have irregular borders, and the slit lamp images would demonstrate thinning.

4.	The gray translucent areas occur in what age patient?
	e -- 70 years old Scleral plaques occur in older individuals with 80.6 years as the mean age of occurrence.  Advanced age is the most common predisposing factor.  The prevalence in patients under 70 years old is approximately 2%, but this rises to 7.2% in those 70-79 years old.

5.

Management should be:

e -- observation There are reports of senile scleral plaques leading to scleral perforation after spontaneously dehiscing as well as progression of senile scleral plaques to senile scleromalacia.  This is exceedingly rare given the incidence of senile scleral plaques that remain asymptomatic throughout a patient’s lifetime. Therefore, simple observation is warranted, and there is no place for medication utilization.

References:

Carroll CP, Peyman GA, Raichand M.  Surgical Management of Senile Scleromalacia.  Ophthalmic Surg.  1980 Oct; 11(10): 719-721.

Gossner, J and Larsen, J. Calcified Senile Scleral Plaques.  J of Neuroradiology 2009 June; 36(2): 119-120.

Lyall DA, Srinivasan S. Scleral Perforation Secondary to a Spontaneously Dehisced Senile Scleral Plaque: Clinical Features and Management. Clin Experiment Ophthalmol. 2010 Jul;38(5):533-4.

Manschot, WA.  Senile Scleral Plaques and Senile Scleromalacia. Br J Ophthalmol. 1978 June; 62(6): 376–380.

Moseley I. Spots Before the Eyes: A Prevelance and Clinicoradiological Study of Senile Scleral Plaques. Clinical Radiology. 2000 March; 55(3): 198-206.

Scroggs MW, Klintworth GK.  Senile scleral plaques: a histopathologic study using energy-dispersive x-ray microanalysis.  Hum Pathol.1991 Jun;22(6):557-62.