Episcerlitis

Question 1

Episcleritis

Answer 1

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

Question 2

What systemic diseases are associated with episcleritis

Answer 2

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

Question 3

Signs of episcleritis

Answer 3

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

Question 4

Phlyctenular keratoconjunctivitis

Answer 4

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

Question 5

Conjunctival phlyctenules

Answer 5

Pink, fleshy nodules with conjunctival injection at the limbus

Question 6

Corneal phlyctenules

Answer 6

Small, white (lymphocytic) nodules located near the limbus with adjacent conjunctival injection (looks like infiltrate)

Question 7

SLK

Answer 7

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

Question 8

Pinguecula

Answer 8

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

Question 9

Scleritis

Answer 9

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

Question 10

Symptoms of scleritis

Answer 10

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

Question 11

Signs of scleritis

Answer 11

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

Question 12

Anterior vs posterior scleritis

Answer 12

Anteiror 98%, posterior 2%

Question 13

Non necrotizing scleritis

Answer 13

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.

Question 14

Necrotizing scleritis

Answer 14

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

Question 15

Differences between scleritis and episcleritis

Answer 15

• 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

Question 16

When should underlying condition be considered in episcelrtiis

Answer 16

Severe, recurrent disease

Usually RA

Question 17

Whorl K and amiodarone

Answer 17

Minimal at a dosage of 100-200mg/day, but inevitable at dosage of 400mg/day

Question 18

Treatment for mild episcleritis

Answer 18

ATs and cold compresses, topical decongestants may also be RXed to reduce injunctive hyperemia

Question 19

Treatment of mod/severe episcleritis

Answer 19

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

Question 20

Scleritis treatments

Answer 20

• 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

Question 21

Pinguecula treamtnte

Answer 21

Not treated unless inflamed

• mild=ATs
• mod/severe=topical steroids, tropical antihistmianes, and/or topical NSAIDs

Question 22

Phlyctenular keratoconjunctivitis treatment

Answer 22

Topical decongestants, topical steroids and/or steroid, abx combos. Underlying etiology needs treated

Question 23

Addison’s disease

Answer 23

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

Question 24

Whorl K

Answer 24

Chloroquine 
Hydroxychloroquine 
Amiodarone 
Indomethacin
Tamoxifen
Fabrys