Episcerlitis Flashcards
Episcleritis
Benign, self limiting inflammation of the episclera. It is most common in young adults with a peak incidence in the 20-40s. Frequent recurrences are common. Often idiopathic but may be assocaited with systemic diseases
What systemic diseases are associated with episcleritis
Collagen vascular/inflammatory disease: RA, SLE, UCRAP
Spirochetes (lyme, syphilis)
Viruses: HZV, HSV, mumps
Metabolic DZ: hour
Vasculitis disease: temporal arteritis, Wagner’s, Behçet’s, polyarteritis nodosa
Acne rosacea
Signs of episcleritis
Acute, unilateral, sectorial conjunctival hyperemia associated with mild ocular discomfort. It may be simple (80%) or nodular (20%); unlike in scleritis, the nodule CAN be moved slightly with a CTA
Phlyctenular keratoconjunctivitis
Type 4 HS to staph and TB protein. Most common during teen years and in females
- symptoms: photophobia, lacrimation, FB sensation, and blepharospasm
- can be located on the cornea or conjunctiva
Conjunctival phlyctenules
Pink, fleshy nodules with conjunctival injection at the limbus
Corneal phlyctenules
Small, white (lymphocytic) nodules located near the limbus with adjacent conjunctival injection (looks like infiltrate)
SLK
Chronic inflammatory reaction most commonly assoacited with keratoconjunctivitis sicca, thyroid disease, and CL wear. It presents with hyperemia of the superior bulbar conjunctiva and the limbus
Pinguecula
Degeneration of collagen fibrils within the conjunctival stroma. They appear as yellow white elevated areas of conjunctiva located at the 3 and 9 o’clock positions and are caused by chronic dryness and/or exposure to UV light. They may become inflamed (pingueculitis), appearing as sectoral injection
Scleritis
Granulomatous inflammation of the sclera that is often gradual in onset and frequently bilateral with diffuse injection. 50% of cases are associated with underlying etiolgoy and 30% of those cases are caused by a collagen vascular disorders (mostly RA). More common in women and much less common than episcleritis
Symptoms of scleritis
Severe boring pain that can radiate to ipsilateral forehead, brow, and/or jaw and cause the patient to wake up in the middle of the night. Pts may also complain of a gradual onset of redness and decreased vision
Signs of scleritis
Sectoral or diffuse inflamamtion of the large, deep vessels with an underlying thin sclera with a classic bluish hue under natural light; signs are typically bilateral
May result in severe, sight-threatening conditions including uveitis, secondary glaucoma, and corneal pathology
Anterior vs posterior scleritis
Anteiror 98%, posterior 2%
Non necrotizing scleritis
Diffuse (60%)
- most common type of anterior scleritis and the most benign form of the disease; associated with the least severe systemic conditions, characterized by diffuse injection
Nodular (25%)
-deep, focal, painful, injected and immobile nodule.
Necrotizing scleritis
With inflammation (5%) - the worst form, 33% of patients may die within a few years as a result of severe AI disease. 40-82% of pts will lose vision; 60% of patients have ocular complications, including anterior uveitis, sclerosing keratitis, peripheral corneal melt, scleral thinning cataracts, and glaucoma.
Without inflamamtion (scleromalacia perforans) - chronic RA. Characterized by alsmot a complete lack of symptoms and minimal injection; patients will present with asymptomatic gray-blue patches of scleral thinning
Differences between scleritis and episcleritis
- scleritis gradual onset, episleritis acute
- scleritis significant pain compared to episcleritis
- scleritis characteristics gray blue hue under natural light, episcleritis appears red
- 2.5% phenyl will blanch episcleritis, not scleritis
- scleritis typically bilateral and diffuse, episcleritis usually unilateral and sectoral
- scleritis much less common than episcleritis, more commonly assocaited with underlying conditions
When should underlying condition be considered in episcelrtiis
Severe, recurrent disease
Usually RA
Whorl K and amiodarone
Minimal at a dosage of 100-200mg/day, but inevitable at dosage of 400mg/day
Treatment for mild episcleritis
ATs and cold compresses, topical decongestants may also be RXed to reduce injunctive hyperemia
Treatment of mod/severe episcleritis
Soft steroids (lotemax QID) or an oral NSAID (ibuprofen 200-600mg), or a combo of topical steroids and oral NSAIDs. RXed for 5-10 days
Scleritis treatments
- eval and treatment of underlying systemic diseases
- oral NSAIDs (ibuprofen 400-600mg QID, indomethacin 25mg TID, naproxen 250-500mg BID), steroids (pred 60-100mg QD x 1 week, then taper to 20mg QD x 2-3 weeks, then an additional taper), or immunosuppressive agents (MTX, azathioprine, cyclosporine)
- topical NOT EFFECTIVE
- eye protection if thinning
- sub tenons injections contraindicated due to thinning
- necrotizing require hispotilzations with IV steroids
Pinguecula treamtnte
Not treated unless inflamed
- mild=ATs
- mod/severe=topical steroids, tropical antihistmianes, and/or topical NSAIDs
Phlyctenular keratoconjunctivitis treatment
Topical decongestants, topical steroids and/or steroid, abx combos. Underlying etiology needs treated
Addison’s disease
Chronic adrenocortical deficiency due to AI atrophy of the adrenal glands. Symptoms include weakness, fatigue, anorexia, weight loss, nausea, and/or vomitting, diarrhea, abdominal pain, muscle and joint pain, and amenorrhea
Whorl K
Chloroquine Hydroxychloroquine Amiodarone Indomethacin Tamoxifen Fabrys
