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Eye Disease > Episcleritis and Scleritis > Flashcards

Episcleritis and Scleritis Flashcards

1
Q

basic anatomy of sclera

A
  • three layers
  • from outer to innermost: epislera, scleral stroma, lamina fusca
  • comprises collagen and proteoglycans
  • connnective tissue
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2
Q

basic anatomy of episclera

A
  • connects sclera to conj
  • lie under Tenon’s capsule
  • loose connective tissue - low friction surface allowing free movement of globe in orbit
  • highly vascular - vessels larger and darker than vessels of conj, and vessels follow a radial pattern
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3
Q

basic anatomy of tenons capsule

A
  • also known as the fascia bulbi
  • thin fibrous sheath
  • envelops globe from limbus to margins of optic nerve
  • inferiorly, tenons capsule is thickened to form the suspensory ligament of lockwood
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4
Q

basic anatomy of the vascular layers

A
  • conj vessels
  • superficial episcleral vessels - radial patetrn
  • deep vascular plexus of sclera
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5
Q

differential diagnosis of a red eye

A

infective - bacterial/viral/fungal conj/keratitis
auto immune - episcleritis/scleritis/uveitis/allergic
acute closed angle glaucoma
trauma - solar/radiation/chemical/latrogenic

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6
Q

differential diagnosis (soap)

A

subjective - what px reports
objective - tests, what you see
assessment
plan

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7
Q

episcleritis aetiology

A

-idiopathic
-inflammation of episclera
-common
-freq recurrent
self limiting - benign, doesnt progress to true scleritis
-usually affects females
-most common in 40s and 50s

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8
Q

subjective clinical characteristics of episcleritis

A
  • red eye, ususally unilateral
  • acute onset (12hrs)
  • discomfort - mild to moderate, non specific irritation ie hot/uncomfortable/gritty
  • sometimes mild tenderness on direct palpation
  • vision unaffected
  • photophobia - mild to moderate- sensitivity to light due to inflammation
  • occasionally mild watering (epiphora)
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9
Q

objective clinical characteristics of episcleritis

A
  • most not associated with systemic condition, up to 30% may have systemic association eg collagen vascular disease, rheumatoid arthiritis, systemic lupus erythematosus, inflammatory bowel disease
  • unilateral in half of cases
  • may have positive POH (ie history of earlier episodes) - may move from eye to eye
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10
Q

assessment of episcleritis

A
  • slit lamp
  • move conj to see if conjunctivitis or episcleritis - gentle pressure on eyelid will move conj over the sclera
  • quiet anterior chamber
  • diagnostic test: topical phenylephrine 10% will blanch conj and episcleral vessels - will make them constrict and become whiter as both are superficial layers - helps to differentiate between episclera and sclera
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11
Q

classification of episcleritis

A

simple (70-75%) - can be further calssified in sectoral and diffuse
- sectoral - inter palpebral (what you see when the eye is open) and apex of wedge to limbus

nodular (30-25%)

  • one or more tender nodules
  • inter palpebral
  • last longer than single type
  • if recurrent vessels may become permanently dilated
  • slit lamp assessment shows deep beam is not displaced above the scleral surface but front beam is displaced
  • nodule will move on palpation
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12
Q

non pharmalogical management of episcleritis

A
  • self limiting, no treatment required - simple resolves 1-2 weeks and nodular resolves 5-6weeks
  • reassurance
  • cool compress and/or artificial tears for symptomatic relief eg hypromellose or g carmellose sodium as necessary for 1-2wks
  • advice px to return/seek medical help if symptoms persist
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13
Q

pharmalogical management of episcleritis

A

if recurrent or persistent (nodular esp) may need topical corticosteroids

  • refer to opthalmologist
  • eg fluorometholone 1-2wks

severe cases may benefit from topical NSAIDs

  • refer to opthalmologist
  • eg flurbiprofen mg tds or naproxen 500mg bd/
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14
Q

aetiology of scleritis - causes and associations

A
  • inflammation of sclera - oedema and cellular infiltration
  • systemic association (50%)
  • infection
  • following surgery
  • females>males
  • middle age 50s
  • bilateral in half of cases
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15
Q

systemic associations of scleritis

A
  • if px comes in with these diseases, assess anterior eye and ask if theyve had red eyes
  • rheumatoid arthiritis
  • wegener granulamatosis
  • relapsing polychondritis
  • systemic lupus erythematosus
  • inflammatory bowel disease
  • ankylosing spondylitis
  • sarcodoisis - crohns
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16
Q

infections associated with scleritis

A
  • herpes zoster, fungal, bacterial

- infections eg spread of infeection from corneal ulcer

17
Q

classification of scleritis

A

anterior (90%) and posterior (10%)
anterior can be non necrotising (75%), which splits again into diffuse and nodular
anterior can also be necrotising, which can be nodular, with inflammation and without inflammation

18
Q

list the 6 subjective clinical characteristics of non necrotising anterior scleritis

A
  • red eye - unilateral or bilateral
  • reduced va
  • severe photophobia
  • epiphora
  • pain or severe comfort
  • more gradual onset than episcleritis
19
Q

list the 7 objective clinical characterisitics of non necrotising anterior scleritis

A
  • deep bluish/purple colour of deeper scleral vessels
  • sclera removes oedematous and thin
  • inflammatory nodules may be apparent on anterior sclera
  • corneal involvement freq with peripheral thinning (keratolysis) and deep stromal endothelial disruption
  • chronic anterior uveitis almost always present
  • check posterior involvement
  • gh: systemic association
20
Q

assessment of non necrotising anterior scleritis

A
  • history and symptoms - onset gradual over several days
  • diffuse
  • nodular - nodule will not move on palpation
  • slit lamp assessment
  • deeper scleral vessel involvement
  • diagnostic test: topical phenylephrine 10% will NOT blanch scleral vessels
21
Q

plan for non necrotising anterior scleritis

A
  • refer to opthalmologist for treament
  • topical corticosteroids eg fluorometholone
  • topical NSAIDs eg flurbiprofen 100mg tds or naproxen 500mg bd
22
Q

list 4 subjective characteristics of necrotsing anterior scleritis with inflammation

A
  • subacute (3-4 days) onset
  • severe deep boring pain, radiates to temple, brow, jaw
  • epiphora with/without photophobia
  • globe v tender to touch
23
Q

list 3 objective characteristics of necrotising anterior scleritis with inflammation

A
  • congestion of deep vascular plexus
  • vascualr occlusion/distortion - results in avascular and ischaemic patches thus necrosis
  • scleral necrosis - translucency reveals blue/black uveal tissue
24
Q

complications of nectrotising anterior scleritis with inflammation

A
  • staphyloma
  • anterior uveitis
  • poor visual prognosis
25
Q

plan for necrotising anterior scleritis with inflammation

A
  • refer!
  • oral steroids eg prednisolone 60-120mg daily
  • pain relief
  • immuno suppressive eg cyclosporin
26
Q

list the 3 subjective characteristics of necrotising anterior scleritis without inflammation

A
  • asymptomatic
  • no redness
  • no pain
27
Q

list the objective characteristics and assessment of necrotising anterior scleritis without inflammation

A
  • yellow necrotic patches in sclera with no inflammation
  • coalesce and progressively expose underlying uvea
  • strong association with rheumatoid arthiritis
  • females
  • on assessment, its usually a quiet eye and usually bilateral
28
Q

plan for necrotising anterior scleritis without inflammation

A
  • refer
  • management of undelying condition
  • NSAIDs and steroid therapy
  • enucleation may be required
29
Q

list 3 subjective characteristics of posterior scleritis

A
  • mid severe deep pain (brow or jaw)
  • reduced vision, depending on whetehr macula is affected
  • diplopia
30
Q

objective characteristics of posterior scleritis

A

range of clinical findings, often misdiagnosed

  • white eye
  • lid oedema
  • proptosis, lid retraction, restricted motility
  • disc swelling, choroidal folds, macular oedema, exudative ret attachment
31
Q

assessment for posterior scleritis

A
  • dilated indirect fundus check
  • ultrasound - t sign
  • ct scan - posterior scleral thickening
32
Q

plan for posterior scleritis

A
  • refer to opthalmologist and physician for treatment of systemic association
  • in elderly px - treat underlying systemic association
  • in young px - NSAIDs

Eye Disease (4 decks)

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