Episcleritis and scleritis

Question 1

what is episcleritis?

Answer 1

Inflammation of outermost layer of the sclera (but deeper than conjunctiva)

Question 2

what are the symptoms of episcleritis?

Answer 2

• Red eye, mild discomfort
• Often asymptomatic
• Does not affect vision

Question 3

what are the signs of episcleritis?

Answer 3

• Localised injection of vessels in the episclera – blanches with instillation of topical phenylephrine (blanching differentiates it from scleritis)
• Hyperaemia may be sectoral (typically interpalpebral i.e. nasal or temporal) or diffuse

Question 4

what is the management of episcleritis?

Answer 4

Usually self-resolving without sequelae; hence treatment is not necessary

Question 5

what is the definition of scleritis?

Answer 5

Full thickness scleral inflammation with maximal congestion in the deep episcleral vascular plexus

Question 6

what is anterior scleritis?

Answer 6

scleral inflammation anterior to the extraocular recti muscles

Question 7

what is posterior scleritis?

Answer 7

Posterior scleritis is defined as involvement of the sclera posterior to the insertion of the rectus muscles.

Question 8

what is scleritis associated with?

Answer 8

30-60% a/w systemic inflammatory disorders, e.g. rheumatoid arthritis (most common), relapsing polychondritis, Wegener’s granulomatosis, polyarteritis nodosa

Question 9

what are the symptoms of scleritis?

Answer 9

• Severe, constant, deep, boring pain - exacerbated by ocular movements because extraocular muscles insert into the sclera. This pain may radiate to involve the ear, scalp, face and jaw.
• Red eye
• *BOV (blurring of vision) (vs episcleritis which spares vision)

Question 10

what are the signs seen in anterior scleritis?

Answer 10

• characteristic violet-bluish hue
• scleral edema and dilatation
• associated keratitis with corneal infiltrates or thinning, uveitis, and trabeculitis

Question 11

what are the signs seen in posterior scleritis?

Answer 11

• characteristic violet-bluish hue
• scleral edema and dilatation
• retinal detachment and optic nerve edema with or without cotton-wool spots

Question 12

what are the complications of scleritis?

Answer 12

• peripheral keratitis, uveitis, cataract and glaucoma
• posterior scleritis: vitritis (cells and debris in vitreous), macular oedema, exudative retinal attachment, optic nerve oedema, visual compromise

Question 13

what investigations would you do with scleritis?

Answer 13

• B scan U/S: **T sign in posterior scleritis (scleral thickening + fluid collection in Tenon space)
• Blood tests (rheumatologic) – RF, c-ANCA, p-ANCA, ANA, anti-dsDNA