episcleritis

Question 1

what are the three layers of the sclera?

Answer 1

. episclera- outer most
. scleral stroma
. lamina fusca- inner layer

Question 2

what are the layers of the sclera made of?

Answer 2

. comprises collagen and proteoglycan

Question 3

what is the function of episclera?

Answer 3

. connects sclera to conjunctiva

. lies under tenon’s capsule

Question 4

what is the episclera made of ?

Answer 4

• loose connective tissue
  . provides a low friction surface allowing free movement of globe in orbit
• highly vascular
  . vessels larger and darker than vessels of conjunctiva
  . vessels follow a radial pattern

Question 5

what is tenon’s capsule?

Answer 5

. known as the fascia bulbi
. thin fibrous sheath
. envelops globe from limbus to margins of optic nerve
. inferiorly, Tenon’s capsule is thickened to form the suspensory ligament of lockwood

Question 6

what is the order of the vascular layers?

Answer 6

. conjunctival vessels

. superficial episcleral vessels
- radial pattern

. deep vascular plexus of the sclera

Question 7

what are the differential diagnosis of a red eye?

Answer 7

. infective
- bacterial/viral/fungal conjunctivitis/keratitis

. autoimmune
- episcleritis/scleritis/uveitis/allergic

. acute closed angle glaucoma

. trauma
- solar/radiation/chemical/iatrogenic

Question 8

what the part you look for in differential diagnosis?

Answer 8

Subjective/ SYMPTOMS- what the px will complain of

Objective/ PHYSICAL EXAM - what you will see as a practitioner

Assessment / TREATMENT- investigation and findings

Plan- split into pharmacological and non-pharmacological management

Question 9

what is the aetiology of episcleritis?

Answer 9

. idiopathic- no specific cause
. inflammation of the episclera
. common
. frequently recurrent
. self limiting - benign, does not progress to true scleritis
. usually affects females
. most common in 40th and 50th decade of life

Question 10

what are the SYMPTOMS / clinical characteristics of episcleritis ( subjective part) ?

Answer 10

. red eye - usually unilateral
. acute onset - 12 hours
. discomfort - mild to moderate- non specific irritation ( hot, uncomfortable/gritty)
. sometimes mild tenderness on direct palpation
. vision unaffected
. photophobia - mild to moderate
. occasionally mild watering ( epiphora)

Question 11

what are the objective characteristics of episcleritis?

Answer 11

. most not associated with systemic condition- it is idiopathic
- up to 30% may have systemic association ( e.g. inflammatory bowel disease)

. unilateral in half of cases

. may have +ive POH (i.e. history of earlier episode)
- may move from eye to eye

Question 12

what is the physical assessment of episcleritis?

Answer 12

. slit lamp
. move conjunctiva to see if conjunctivitis or episcleritis

. quiet anterior chamber

Question 13

what is a useful test to distinguish between episcleritis and scleritis ?

Answer 13

. topical phenylephrine 10% will blanch conjunctival and episcleral vessels

. if the eye is still red, then the diagnosis is scleritis- it won’t blanch because it only effects more superficial blood vessels
.if eye is not red , after installation- whitened by phenylephrine- diagnosis - episcleritis

-or can use a vasoconstrictor

Question 14

what is the classification of episcleritis?

Answer 14

1. simple
   - sectoral- see a section that is red
   - diffuse - redness all over

2.nodular - nodule, visible red raised area surrounded by dilated blood vessels

Question 15

what is the difference between simple and nodular episcleritis?

Answer 15

1. simple
   - 70-75% cases
   - can be sectoral where you get an apex of wedge to limbus
   - can be diffuse
2. nodular
   - 30-25% cases
   - one or more tender nodules
   - lasts longer than simple type
   - if recurrent, vessels may become permanently dilated

Question 16

what to do when looking a slit lamp and you suspect a case of nodular episcleritis?

Answer 16

. the slit lamp assessment will show that the deep beam is not displaced above the scleral surface

. nodule will move on palpation

. you can move the nodule if you press the lid

Question 17

what is the management / treatment of episcleritis?

Answer 17

1. non- pharmacological
   - self limiting; no treatment required
   . simple resolves 1-2 weeks
   . nodular resolves 5-6 weeks

. cold compress and / or artificial tears for symptomatic relief

. advice px to return/seek medical help if symptoms persist

2. pharmacological management

. if recurrent/persistent ( nodular especially) may need topical corticosteroids

• refer to ophthalmologist
• e.g. fluorometholone 1-2 weeks

. severe cases may benefit from topical NSAIDs

• refer to ophthalmologist
  e. g. flurbiprofen 100mg or naproxen 500mg twice a say