Episcleritis and Scleritis Flashcards
basic anatomy of sclera
- three layers
- from outer to innermost: epislera, scleral stroma, lamina fusca
- comprises collagen and proteoglycans
- connnective tissue
basic anatomy of episclera
- 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
basic anatomy of tenons capsule
- 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
basic anatomy of the vascular layers
- conj vessels
- superficial episcleral vessels - radial patetrn
- deep vascular plexus of sclera
differential diagnosis of a red eye
infective - bacterial/viral/fungal conj/keratitis
auto immune - episcleritis/scleritis/uveitis/allergic
acute closed angle glaucoma
trauma - solar/radiation/chemical/latrogenic
differential diagnosis (soap)
subjective - what px reports
objective - tests, what you see
assessment
plan
episcleritis aetiology
-idiopathic
-inflammation of episclera
-common
-freq recurrent
self limiting - benign, doesnt progress to true scleritis
-usually affects females
-most common in 40s and 50s
subjective clinical characteristics of episcleritis
- 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)
objective clinical characteristics of episcleritis
- 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
assessment of episcleritis
- 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
classification of episcleritis
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
non pharmalogical management of episcleritis
- 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
pharmalogical management of episcleritis
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/
aetiology of scleritis - causes and associations
- inflammation of sclera - oedema and cellular infiltration
- systemic association (50%)
- infection
- following surgery
- females>males
- middle age 50s
- bilateral in half of cases
systemic associations of scleritis
- 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
infections associated with scleritis
- herpes zoster, fungal, bacterial
- infections eg spread of infeection from corneal ulcer
classification of scleritis
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
list the 6 subjective clinical characteristics of non necrotising anterior scleritis
- red eye - unilateral or bilateral
- reduced va
- severe photophobia
- epiphora
- pain or severe comfort
- more gradual onset than episcleritis
list the 7 objective clinical characterisitics of non necrotising anterior scleritis
- 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
assessment of non necrotising anterior scleritis
- 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
plan for non necrotising anterior scleritis
- refer to opthalmologist for treament
- topical corticosteroids eg fluorometholone
- topical NSAIDs eg flurbiprofen 100mg tds or naproxen 500mg bd
list 4 subjective characteristics of necrotsing anterior scleritis with inflammation
- subacute (3-4 days) onset
- severe deep boring pain, radiates to temple, brow, jaw
- epiphora with/without photophobia
- globe v tender to touch
list 3 objective characteristics of necrotising anterior scleritis with inflammation
- congestion of deep vascular plexus
- vascualr occlusion/distortion - results in avascular and ischaemic patches thus necrosis
- scleral necrosis - translucency reveals blue/black uveal tissue
complications of nectrotising anterior scleritis with inflammation
- staphyloma
- anterior uveitis
- poor visual prognosis
plan for necrotising anterior scleritis with inflammation
- refer!
- oral steroids eg prednisolone 60-120mg daily
- pain relief
- immuno suppressive eg cyclosporin
list the 3 subjective characteristics of necrotising anterior scleritis without inflammation
- asymptomatic
- no redness
- no pain
list the objective characteristics and assessment of necrotising anterior scleritis without inflammation
- 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
plan for necrotising anterior scleritis without inflammation
- refer
- management of undelying condition
- NSAIDs and steroid therapy
- enucleation may be required
list 3 subjective characteristics of posterior scleritis
- mid severe deep pain (brow or jaw)
- reduced vision, depending on whetehr macula is affected
- diplopia
objective characteristics of posterior scleritis
range of clinical findings, often misdiagnosed
- white eye
- lid oedema
- proptosis, lid retraction, restricted motility
- disc swelling, choroidal folds, macular oedema, exudative ret attachment
assessment for posterior scleritis
- dilated indirect fundus check
- ultrasound - t sign
- ct scan - posterior scleral thickening
plan for posterior scleritis
- refer to opthalmologist and physician for treatment of systemic association
- in elderly px - treat underlying systemic association
- in young px - NSAIDs
