Episcleritis

Question 1

What is episcleritis?

Answer 1

An idiopathic inflammation of the vascular connective tissue that lies between the sclera and conjunctiva

Question 2

Define Idiopathic

Answer 2

relating to or denoting any disease or condition which arises spontaneously or for which the cause is unknown.

Question 3

What is scleritis?

Answer 3

A severe inflammatory disease of the sclera which is bilateral in 50% of cases.

Question 4

How many layers is the sclera made up of and what are they?

Answer 4

3 Layers.

Episclera

Scleral stroma

Lamina fusca

Question 5

What are the layers of the sclera made up of?

Answer 5

Collagen and proteoglycans

Question 6

What does the episclera do and where does it lie?

Answer 6

It connects the sclera to the conjunctiva. It lies below the tenon’s capsule.

Question 7

What are properties of the episclera?

Answer 7

It is a loose connective tissue

• It has a low friction surface allowing free movement of globe in orbit
• It is Highly vascular
• Vessels of the episclera are larger and darker than vessels of the conjunctiva
• Vessels follow a radial pattern

Question 8

What is the tenon’s capsule also known as?

Answer 8

The Fascia Bulbi

Question 9

What is the tenon’s capsule?

Answer 9

A thin fibrous sheath that envelops the globe from limbus to margins of optic nerve.

Question 10

What’s the relationship between the tennon’s capsule and the suspensory ligament of lockwood?

Answer 10

Inferiorly, Tenon’s capsule is thickened to form the suspensory ligament of Lockwood

Question 11

What is a ligament?

Answer 11

a short band of tough, flexible fibrous connective tissue which connects two bones or cartilages or holds together a joint.

[A suspensory ligament is a ligament that supports a body part]

Question 12

How are vascular layers of the ocular surface arranged?

Answer 12

Question 13

What are all the different causes of red eye?

And what are examples of each cause?

Answer 13

Question 14

How do we diagnose conditions?

Answer 14

SOAP

Subjective - find out what patient complains about ( this can vary)

O- Objective - look at what you see as an eye practitioner

A-assessment- As part of an Investigation - do the right test to get the right Findings

Plan - this could be split into pharmacological or non-pharamcological

(plans should always be time sensitive)

Question 15

What is the aetiology of episcleritis?

Answer 15

• Idiopathic
• Inflammation of the episclera

Question 16

Is episcleritis common?

What type of patient is more likely to have episcleritis?

Answer 16

Yes

Females ( 60% of cases are female , 40% of cases are male)

Question 17

Can we visibly see the episclera?

Answer 17

Normally No as its very deep, however, when it is inflammed we can see it.

Question 18

Is episcleritis frequently recurrent?

Answer 18

Yes

Question 19

Is episcleritis self limiting?

Answer 19

Yes

[It is Benign. It does NOT progress to true scleritis]

Question 20

What age group is episcleritis most common in?

Answer 20

Most common in 40th or 50th decade of life

Question 21

What are the SUBJECTIVE clinical characteristics of Episcleritis?

Answer 21

• Red eye - usually unilateral
• Acute onset ~12 hours
• Discomfort - mild to moderate –>Non specific irritation i.e. hot/uncomfortable/gritty
• Sometimes mild tenderness on direct palpation (means to touch) (obviously when eyelid is closed)
• Vision unaffected
• Photophobia - (don’t like light) mild to moderate
• Occasionally mild watering (epiphora)

Question 22

What are the OBJECTIVE characteristics of Episcleritis?

(i.e. what the optometrist sees/is looking for)

Answer 22

Most not associated with systemic condition

• Up to 30% may have systemic association - Collagen vascular diseases: rheumatoid arthritis; systemic lupus erythematosus; inflammatory bowel disease
• Unilateral in half of cases
• May have +ive Previous Ocular History (POH) (i.e. history of earlier episode) - May move from eye to eye

Question 23

How would the assesment for episcleritis occur and what would we be looking for?

Answer 23

This would be done using a slit lamp.

You would move the conjunctiva to see if it is conjunctivitis or episcleritis.

The anterior chmaber will be quiet - you won’t see any inflammation there.

Use phenylephrine 10%.

Question 24

How do we identify between episcleritis and scleritis?

Answer 24

We use an important diagnostic tool called phenylephrine 10%.

This will blanch ( this means to whiten out) conjunctival and episcleral vessles.

So basically if the eye is still red after we have added this to the eye, then the diagnosis is scleritis. If the eye isn’t red after installation, the diagnosis is episcleritis.

Question 25

What are the two main types of episcleritis?

Answer 25

Simple or Nodular Episcleritis.

Question 26

What are the two sub-types of simple episcleritis?

Answer 26

Sectoral - this means a small section showing that inflammation.

Diffuse - this would be inflammation across the entire surface.

Question 27

What is nodular episcleritis?

Answer 27

Episcleritis where you can see a nodule ( a red raised area surrounded by dilated blood vessels).

Question 28

Which type of episcleritis is more common?

Answer 28

Simple episcleritis is more common than nodular episcleritis. ( 70 vs 30)

Question 29

Which type of episcleritis lasts longer?

Answer 29

Nodular episcleritis lasts longer than simple episcleritis

Question 30

If nodular episcleritis is recurrent what may happen?

Answer 30

Vessels may become permanently dilated.

Question 31

How can we identify nodular episcleritis from a slit lamp?

[Rememeber sometimes it doesn’t look as obvious]

Answer 31

Slit lamp assessment shows deep beam is NOT displaced above the scleral surface

• Nodule will move on palpation (upon touch)

Question 32

How does managment of episcleritis occur?

Answer 32

• This can depend on the type of episcleritis.
• Typically non-pharamcological as simple and nodular episcleritis tend to be self-limiting.

Simple resolves in 1-2 weeks

Nodular resolves in 5-6 weeks.

• Provide reasurrance to the Px.
• Cool compress and/or artificial tears for symptomatic relief
• Advise patient to return/seek medical help if symptoms persist

Question 33

How would pharamcological managment of episcleritis occur?

Answer 33

—–> If recurrent/or persistent (nodular especially) Px may need topical corticosteroids

• E.g. fluorometholone 1-2 weeks

——> Severe cases may benefit from topical NSAIDs (Non-Steroidal Anti Inflammatory Drugs)

• E.g. flurbiprofen 100mg tds or naproxen 500mg bd

In both cases refer to an ophthamologist.