Episclera and Sclera Flashcards
what is the episclera made up of?
loose, fibrous elastic tissue (collagen) that contains blood vessels that nourish sclera
how is the episclera connected to the sclera?
by fascia bulbi (tenon’s capsule)
who typically gets episcleritis and how does it present?
mainly in females (20-40 years old), unilateral, benign (stress/hormonal changes)
what are the signs of episcleritis?
cornea is typically unaffected, anterior chamber is deep and quiet, sectoral redness/inflammation and mild edema
what are the symptoms of episcleritis?
range from mild-moderate: “feels hot” or uncomfortable, some tenderness on palpation, photophobia, mild tearing, acute onset
what are the two types of episcleritis?
simple (80%) and nodular (20%)
what is simple episcleritis?
diffuse or sectoral inflammation (usually more sectoral) - without nodule
what is nodular episcleritis?
discrete elevated area of inflamed episcleral tissue (more painful, prolonged 2-3 months and moveable)
what are some differential diagnoses for episcleritis?
conjunctivitis, scleritis, pinguecula/pterygium, phlyctennular conjunctivits or direct trauma (mechanical or chemical)
what happens when you perform a 2.5% phenylephrine test?
the drop will blanch or vasoconstrict the superficial vessels - if that happens you know it is episcleritis not scleritis
what causes episcleritis?
70% is idiopathic - connective tissue/vascular disease, infectious disease (herpes simplex or zoster, syphilis, lyme), dermatologic (rosacea), or atopic disease
what is some important patient education for episcleritis?
duration of treatment - can last up to 2-3 weeks and nodular can be 2-3 months there can be a recurrence up to 3-4 years
how do you treat mild cases of episcleritis?
topical vasoconstrictors/antihistamines (2-3 weeks) = Visine, Naphcon-A (be careful for rebound hyperemia)
Topical NSAIDs
how do you treat moderate to severe cases of episcleritis?
topical steroids (q1-2 hours QID) = Alrex, FML, prednisolone acetate need to monitor IOP
what are some oral NSAIDs used for episcleritis?
ibuprofen (800mg TID), Naproxen (250mg BID), and Indomethacin (25mg TID)
what is the sclera made of?
white, opaque, dense irregular collagen fibrous tissue
what is scleritis?
chronic, painful (severe stabbing pain), and potentially blinding inflammatory disease - rare condition that is typically associated with a systemic disease
what characterizes scleritis?
edema and cellular infiltration
who does scleritis typically affect and how does it present?
females over age 40
50% bilateral with unilateral presentations becoming bilateral in 5 years
what are some signs of scleritis?
sclera will have a bluish hue, vessels become engorged and tortuous, edema, peripheral cornea can become involved and anterior uveitis can be present
what are some symptoms of scleritis?
severe boring pain that radiates to forehead, brow, jaw and can wake patient up at night, gradual onset, inflammation, tearing/photophobia, decrease in VA
what are the 3 inflammatory types of anterior scleritis?
diffuse (90%), nodular (5%) and necrotizing (5%)
what is the 1 non-inflammatory type of scleritis and what is it?
scleromalacia perforans = necrosis of sclera without inflammation or ocular pain, due to arteriolar occlusion (usually elderly females with RA)
what is diffuse anterior scleritis?
most common form - doesn’t blanch with 2.5% phenylephrine, non-granulomatous inflammatory reaction, recurrence is common and has corneal involvement
what is nodular anterior scleritis?
single or multiple nodules, tends to occur in same site (superior sclera), nodules at limbus can raise IOP, associated with RA nodules in 1/3 of cases
what is necrotizing anterior scleritis?
most severe form - always associated with systemic disease, areas of necrotic scleral tissue, more than 60% develop complications other than scleral thinning, 40% vision loss
what are the signs of posterior scleritis?
only presents with a few signs unless the anterior segment is also involved - subretinal granuloma, exudative retinal detachment, proptosis, or rapid onset hyperopia
what are some symptoms of posterior scleritis?
poor/decreased vision, diplopia, severe pain and proptosis
what will you see on a DFE with posterior scleritis?
papilledema, choroidal folds, CME, retinal hemorrhage or detachment
how do you diagnose posterior scleritis?
B-scan ultrasound
what is the etiology of scleritis?
43% may occur in isolation or in association with: autoimmune (50%), infectious (7%), or miscellaneous (2%)
what are some autoimmune causes of scleritis?
connective tissue disease = RA, lupus
CRAP = chrohns, reactive arthritis (Reiter’s), ankylosing spondylitis, and psoriatic arthritis, gout
Vasculitis diseases = polyarteritis nodosa, wegener granulomatosis, behcet disease, giant cell arteritis
what are some infectious disease causes of scleritis?
bacterial, fungal, viral or parasitis (herpes zoster, simplex, syphilis, and lyme)
what are some miscellaneous causes of scleritis?
rosacea, atopy, secondary to FB, chemical injuries or drugs
what are some other ocular complications that can occur with scleritis?
uveitis (usually with necrotizing), keratitis, glaucoma, cataract (PSC), retinal changes (CME, ONH edema, RD, choroidal folds)
what is the initial treatment for diffuse/nodular scleritis?
oral NSAIDs = ibuprofen, indomethacin, naproxen (contraindications = peptic ulcer, recent GI bleed, renal insufficiency)
what is the treatment if oral NSAIDs aren’t working or scleritis is severe/necrotizing?
oral corticosteroids = prednisone (1mg QD or 60-100mg) use with antacid or H2 blocker
what do you use for scleritis if oral corticosteroids aren’t working or patient has systemic vasculitis/necrotizing?
immunosuppressive drugs = methotrexate, cyclophosphamide (supplemented with oral steroids)
what type of steroid should not be given for necrotizing scleritis or peripheral ulcerative keratitis?
periocular steroid injections or topical steroids
what type of surgery can be performed for scleritis?
scleral grafts
can scleritis cause episcleritis?
yes - but not the other way around
what is thinning/extasia?
bulging of uveal tissue thru thinning sclera (anterior = inflammation and posterior = high myopia)
what is icteric sclera?
typically bilateral yellow discoloration to sclera - indication of acute or chronic liver disease (high concentration of bilirubin in blood)
what can icteric sclera be an indication of in adults and infants?
adults = inflammation/infection, cancer, alcoholism
infants = physiologic, related to breastmilk
what is blue sclera?
an increase in melanin (nevus of ota) - common in infants, hallmark sign for osteogenesis imperfecta and other connective tissue disorders (Marfans, ehler’s, danlos)
what is an axenfeld loop?
posterior ciliary nerve that has pierced the sclera - usually adjacent to limbus
what is ocular melanosis (complexion-related)?
benign - increased pigmentation of basal epithelial cells, pigmentation because lighter as you move peripherally
what are hyaline plaques?
common in older patients - no symptoms (consider scleromalacia perfomans if overlying tissue is intact)
what is ocular melanosis (primary acquired)?
an increase in number of melanocytes, unilateral flat patch of pigment seen in middle-aged patients (46% can progress to melanoma)
blue sclera
thinning/ectasia
icteric sclera
Episcleritis
Hyaline plaque
Ocular Melanosis
nodular episcleritis
Scleritis
nodular scleritis
necrotizing scleritis
Scleromalacia perfoans
