DIS - Scleritis and Episcleritis - Week 6 Flashcards
Is episcleritis generally benign or sinister?
Benign
True or false
Cases of scleritis and episcleritis tend to have similar complications, causes, and management
False
Dramatically different for all three
Is scleritis generally benign or sinister?
Sinister, has many longterm complications
What are the three key layers associated with scleritis and episcleritis?
Tenon’s capsule
Episclera
Sclera
What is tenons capsule?
Separates episclera from conjunctiva
What can the episclera be considered as? What does it allow for? What can it also act as?
The synovial lining to the sclera
Allows smooth movement of the globe
Acts as a check ligament for excessive movement
Describe the thickness of the episclera anterior and posterior to rectus insertion.
Thick anterior to rectus insertion
Thin posterior to rectus insertion
True or false
The episclera is dense
True
What provides nutrition to the scleral stroma?
Episclera
What are the blood vessels of the episclera derived from (2)? Are they generally visible when not inflamed? What pattern do they have?
Derived from anterior/posterior ciliary arteries
Barely visible when not inflamed
With inflammation, radiating pattern is visible
Are episcleral blood vessels generally affected by vasoconstrictors?
No
What can be found between tenons fascia and the sclera posteriorly in the eye?
Tenons space
Does tenons capsule slow down drug delivery or is its effect negligible? Give an exmaple.
Slows down drug delivery
-vasodilators have a good effect on conjunctival vessels but little to none on episcleral vessels
How thick is the sclera generally?
1mm
How thick is the sclera under EOM insertion?
0.3mm
Is the sclera generally very vascular or avascular? What is its metabolic activity like?
Avascular
Low metabolic activity
Where does the sclera derive its nutrition from (5)?
Episclera
Choroid
Branches of the anterior ciliary arteries and long/short posterior ciliary arteries
True or false
Nerves and blood vessels pass through the sclera to the uvea and anterior segment
True
Does inflammation/destruction of nerves with scleritis tend to cause pain?
Yes, severe pain
What drop can be used to differentiate episcleritis, scleritis, and conjunctivitis? Describe how and what you expect to see for each.
With 2.5% phenylephrine
Conjunctivitis from episcleritis
-episcleritis will take longer for blood vessels to blanch
-scleritis will not blanch
What age range does scleritis and episcleritis tend to occur?
Episcleritis - 20 to 40
Scleritis - 20 to 60
What gender is predisposed to scleritis and episcleritis?
Female for both
Between scleritis and episcleritis, in which are complications more common?
Scleritis
What is generally the prognosis for scleritis and episcleritis?
Episcleritis - excellent
Scleritis - variable but can be aweful
Between scleritis and episcleritis, in which are systemic associations more common? Especially which systemic condition?
Scleritis
-especially rheumatoid arthritis
What are the two forms of episcleritis? Give percentages.
Simple - 80%
Nodular - 20%
What are the two forms of scleritis? Give percentages.
Anterior - 98%
Posterior - 2%
What are the two forms of anterior scleritis? Give percentages.
Necrotising - 85%
Non-necrotising - 13%
What are the two forms of anterior non-necrotising scleritis? Give percentages.
Diffuse - 40%
Nodular - 45%
What are the two forms of anterior necrotising scleritis? Note which of thse is the nasty one.
Inflammatory
-nasty one
Scleromalacia
-non-inflammatory
Is simple episcleritis granulomatous ornon-granulomatous?
Non-granulomatous
Where is simple episcleritis localised to?
Superficial episcleral vascular network
List 6 symptoms and presentations of simple episcleritis.
Red eye (generally one sector)
Acute onset
Non-specific irritation/heat/discomfort
Tenderness on palpation
Mild photophobia/watering
Previous episodes
What is vision like with simple episcleritis?
Normal
What shape does hyperaemia in simple episcleritis have? What pattern do the vessels have?
Generally wedge shaped, apex to the limbus
-radiating pattern
Do you expect blanching on pressure/vasoconstrictors with simple episcleritis? Do vessels move with a cotton bud?
No blanching or moving
What can be used to highlight vascular congestion and vascular areas?
Red-free filter
Do you expect to see oedema with simple episcleritis?
Yes
Do you expect to see infiltrates with simple episcleritis?
Yes
Do you expect to see corneal changes with simple episcleritis?
No
-possible dellen from drying
Do you expect to see any anterior chamber reaction with simple episcleritis?
No
-possible minimal AAU
What is nodular episcleritis like compared to simple episcleritis?
Similar but more intense than simple episcleritis
With what three other diseases does nodular episcleritis have an association with? Is it strong or weak?
rheumatoid arthritis
Revious HZO
Gout
-slightly stronger association
What are the signs of nodular episcleritis (2)?
As with simple episcleritis with the addition of a raised mobile congested nodule
Consider the nodule in nodular episcleritis. Describe what can be seen at the centre, note if the scleral surface beneath is raised, and what you expect to see on slit lamp (the beam).
Infiltrate at the centre of the wedge
Scleral surface not raised
Separation of anterior and posterior slit beams
Do you expect to see any anterior chamber reaction with nodular episcleritis?
Mild reaction possible
Is nodular episcleritis generally recurrent? What may happen over time? Hint. make a note of thinning.
Yes
-slight translucency of the superficial sclera over time
-not considered thinning
List 7 differential diagnoses for episcleritis.
Conjunctivitis
Inflamed pingueculum/pterygium/phlycten
Scleritis
Kaposi’s sarcoma
Other limbal malignancy (OSSN)
History of connective tissue disease
What is the management of episcleritis ().
Self-limiting
-no action warranted
What three things can be done for palliative care of episcleritis?
Frequent hot compresses
Lubricants
Vasoconstrictors
-generally not recommended unless for a one-off thing - events, pictures, etc
Are steroids generally considered for episcleritis? What else may be considered?
Only if necessary, mild topical steroid pulsed dose
-oral NSAID (ibuprofen/naproxin)
What is used for more severe cases of episcleritis?
More potent steroids
-prednisolone
Oral aspirin/NSAID
What is generally recommended for recurrent cases of episcleritis?
Medical workup
Are cases of nodular episcleritis generally quicker or slower to resolve vs simple?
More indolent
-slower to resolve
Describe the pathogenesis of scleritis (2). Is it granulomatous or non-granulomatous? What disease is it often associated with?
Auto-immune
-circulating immune complexes
-granulomatous
-associated with vasculitis
What are immune complexes?
Combination of antigen (epitope) / antibody
What may immune complexes attract (3)?
Complement
Pagocytosis
Protease reaction
Do immune complexes generally excite or dampen diseases?
Excite
List 4 conditions associated with scleritis. Note the most common first and give its percentage.
Rheumatoid arthritis - 50%
Regner granulomatosis
Polychondritis
Polyarteritis nodosa
What percentage of rheumatoid arthritis patients who develop scleritis will die within 3 years? Especially what form of scleritis? What is this due to?
40%
Especially necrotising scleritis
-due to extra-articular (joint) manifestations
-indicating vasculitis/RA activity outside joints
List four anterior segment surgeries associated with scleritis.
Scleral buckling
Trabeculectomy
Pteygium (surgery/radiation)
Vitrectomy (ports)
List a virus associated scleritis.
HZO
List three bacterial infections associated with scleritis.
Pasudomonas
Norcadia
Staphylococcus
List two fungal infections assocciated with scleritis.
Aspergillus
Scedosporium
List a drug class associated with scleritis.
Bisphosphonates
List four symptoms of scleritis.
Pain
Photophobia
Lacrimation
Globe tender on palpation
Describe whether the symptom onset of scleritis is acute or gradual.
Gradually builds up
What is responsible for the excrutiating pain with scleritis?
Involvement or stretching of nerve endings
What are symptoms of scleritis liek compared to episcleritis?
Each symptom is more severe than episcleritis
Why is there a purple hue with scleritis?
Deep vascular plexus congestion
What can be seen with diffuse anterior non-necrotising scleritis? What pattern do vessels have?
Widespread inflammation (>90 degrees)
Normal radial vessel pattern is distorted
Is diffuse anterior non-necrotising scleritis benign or sinister? What is progression to other forms of scleritis like and what is the prognosis?
Relatively benign
Generally no progression to other forms of scleritis
Generally reasonable prognosis with treatment
What is the management for diffuse anterior non-necrotising scleritis (2)?
Refer
-similar management to severe episcleritis
What is nodular anterior non-necrotising scleritis similar to? What is the difference (2)? Compare the symptoms.
Nodular episcleritis
-nodule is not moveable/mobile
-tender to touch
-the symptoms are more severe
Is the slit beam displaced when assessing the nodule in nodular anterior non-necrotising scleritis?
Yes
Does necrosis follow in nodular anterior non-necrotising scleritis?
Not
What is the management for nodular anterior non-necrotising scleritis (4)? Note the drug, dosage and duration. What is there a risk of?
Refer
Topical steroids
-pred forte 1% q2h 4 days then qid
Oral steroid or NSAID
Subconjunctival steroid injection
-risk of scleral melt
Is anterior necrotising scleritis with inflammation severe or mild? Is it typically uni- or bilateral (explain)? Are systemic associations common or rare? What is the associated percentage of mortality within 5 years?
Severe/distressing
Bilateral (alternating)
Systemic associations are common
-25% mortality within 5 years
What is the symptom of anterior necrotising scleritis with inflammation (2)?
Gradual onset of pain/redness
-builds into severe persistent pain - temple, brow, jaw
When there is limbal involvement with anterior necrotising scleritis with inflammation, what is there a risk of and what is this called?
Risk of corneal involvement
-sclerokeratitis
List 7 signs of anterior necrotising scleritis with inflammation.
Congestion of deep vascular plexus
Intense oedema
Vascular distortion
Vascular occlusion
Scleral necrosis
Coalscing necrosis
Thinning/blueish tinge
What causes the white avascular patches in anterior necrotising scleritis with inflammation?
Vascular occlusion
When do you expect to see oedema with anterior necrotising scleritis with inflammation?
Initially
What causes the bluish tinge seen in anterior necrotising scleritis with inflammation?
Scleral thinning
-underlying uvea shows
With vitrectomy, what can scleritis develop around?
Ports
List two complications of anterior necrotising scleritis with inflammation that can occur?
Staphyloma
Anterior uveitis
What is the referral for anterior necrotising scleritis with inflammation (3)?
Urgent referral
Oral prednisolone
-high dose, short duration
Immunosuppressant drugs
Combined steroid/immunosuppressive agents
What is anterior necrotising scleritis without inflammation also known as?
Scleromalacia perforans
Which gender does scleromalacia perforans typically affect more? Is it uni- or bilateral? What do patients typically have alongside it?
Female
Bilateral
Longstanding rheumatoid arthritis
What lesion can be seen with scleromalacia perforans (note colour)? Are they symptomatic? Is inflammation present? What happens to these lesions? Does scleral thinning occur with this disease?
Asymptomatic yellow plaques
-without scleral inflammation
-enlargement, spread, and coalescence
-scleral thinning, uvea visible
Are staphylomas common with scleromalacia perforans?
Uncommon
What is the treatment for scleromalacia perforans?
No effective treatment
List 5 differental diagnoses for scleritis.
Corneal surface disease
-ulcer, trauma, UV, CL related
Angle closure glaucoma
Uveitis (complicated by scleritis)
Retrobulbar mass
Staphyloma/ectasia
Is posterior scleritis common or uncommon? Is it easy or difficult to diagnose? Explain why.
Uncommon
Difficult to diagnose
-confused with other inflammation or mass lesions
Which gender is typically more affected by posterior scleritis?
Females
List two symptoms of posterior scleritis.
Pain
Visual loss/disturbance
List four external signs of posterior scleritis.
Lid oedema
Proptosis
Ophthalmoplegia
Anterior scleritis
List five fundus signs of scleritis.
Disc oedema
Macular oedema
Choroidal folds
Exudative retinal detachment
Subretinal lipids
What four posterior assessments and tests should be done for posterior scleritis?
BIO
Ultrasound
CT scan
DFE
List 6 differential diagnoses for posterior scleritis.
Optic neuritis
Rhegmatogenous retinal detachment
Choroidal tumour
Orbital mass/inflammation
Uveal effusion syndrome
Intraocular lymphoma
What is the management for posterior scleritis (2)?
Refer
Similar to anterior necrotising scleritis
What test is the key to diagnosing posterior scleritis and what do you expect to see (3)?
Ultrasound
-thickened posterior sclera >2mm
-fluid in tenons space
-optic nerve shadow
-forms a T sign
