Episcleritis, Scleritis And Keratitis Flashcards
What is episcleritis?
Episcleritis is inflammation of the superficial, episcleral layer of the eye. It is relatively common, benign and self-limiting.
Episcleritis does not progress to scleritis.
Differentiation between episcleritis and scleritis is through examination of the layers of blood vessels that are inflamed.
What is the classification of episcleritis?
Simple episcleritis
Nodular episcleritis
What is simple episcleritis?
Characterised by vascular congestion on an even episcleral surface. This can affect a single segment of the episclera or all of it (diffuse episcleritis).
What is nodular episcleritis?
Characterised by a discrete elevated area of inflamed episclera.
How long does it take for episcleritis to resolve?
Episcleritis lasts 7-10 days before spontaneously resolving. If there are underlying systemic predisposing conditions, episodes may be more prolonged.
Nodular episcleritis is more severe and takes longer to resolve. It is also much more likely to be associated with systemic disease.
What is the presentation of episcleritis?
Acute onset of red eye that may be painful.
Episcleral vessels can be moved with a cotton bud. When phenylephrine 10% is applied, they blanch (this will also dilate the pupil).
No associated ocular symptoms.
VA normal
Discomfort, grittiness, aching in or around the eye.
Watering and mild photophobia.
Recurrent episodes are common.
What are the investigations for episcleritis?
A simple case of episcleritis need not be investigated once a thorough history is taken and examination is carried out to rule out the possibility of an associated systemic disease.
If there is a suspicion, biochemical tests should be performed as guided by concern (eg, antinuclear antibody, rheumatoid factor, serum uric acid levels, etc).
Patients who are more likely to have associated conditions include those with nodular disease and individuals with severe recurrent episodes.
What are the associated diseases of episcleritis?
Commonly idiopathic
UC and Crohn’s disease
RA, SLE, Lyme disease, hep. B, rosacea and thyroid eye disease.
What is the management of episcleritis?
Episcleritis can be uncomfortable, although it is not usually described as painful by patients and treatment focuses on decreasing symptoms with lubricating eye drops of ointment.
More severe cases may be treated with topical corticosteroids or oral anti-inflammatory medications.
Artificial tears may provide some relief, particularly in nodular disease.
The use of topical non-steroidal anti-inflammatory drugs (NSAIDs) can be helpful in more symptomatic patients.
Where the episode is more severe, a short course of topical steroids may be required (under the supervision of an ophthalmologist).
Nodular episcleritis may respond best to oral NSAIDs.
It is important to review patients (a week after initial presentation is adequate) to ensure resolution of symptoms.
If the episode is severe, not resolving or if it recurs more than three times, it is appropriate to refer to the Eye Clinic.
What are the complications of episcleritis?
Complications more commonly occur in those patients who have repeatedly required topical steroid treatment over a number of years.
They include cataract formation, ocular hypertension and steroid-induced glaucoma. There may also be rebound inflammation from steroid withdrawal.
What is scleritis?
Scleritis is inflammation involving the sclera. It is a severe ocular inflammation, often with ocular complications, which nearly always requires systemic treatment.
What is the classification of scleritis?
Anterior scleritis
Posterior scleritis
What is anterior scleritis?
Diffuse- this is the most common and benign form. It tends to resolve and it is a widespread inflammation of the anterior sclera.
Nodular- Erythematous, tender, fixed nodules in the sclera which may progress to necrotising scleritis. It commonly recurs.
Necrotising:
- With corneal inflammation- also known as sclerokeratitis
- Without inflammation- it is bilateral and is only seen with advanced RA. It is a severe disorder of the globe with insidious onset, slow progression and a lack of symptoms until the bare choroid is seen under the thin layer of the conjunctiva.
What is posterior scleritis?
Affects the back of the eye and is rare and difficult to diagnose.
Presents with severe eye pain, retinal detachment, choroidal folds and loss of vision.
Can lead to rapid permanent visual loss.
What is the presentation of scleritis?
Subacute or gradual onset (In scleromalacia perforans and posterior scleritis there may be no anterior redness).
Presents early, as symptoms are severe.
Boring eye pain, often radiating to the forehead, brow and jaw and usually severe. Worst in necrotising scleritis; may be mild or absent in scleromalacia perforans.
Pain worse with movement of the eye and at night (may wake the patient).
50% bilateral.
Localised or diffuse red eye.
Associated watering, photophobia.
No discharge other than watering.
Gradual decrease in vision.
Diplopia (posterior disease).
Occasional associated systemic symptoms (fever, vomiting, headache).
Scleromalacia perforans may present with minimal/no symptoms.
Posterior scleritis may present with very severe symptoms but a quiet white eye.
Rarely, posterior scleritis presents with decreased visual acuity in the absence of pain.
Recurrent episodes are common.
Commonly associated with systemic disease which may be severe.
What are the signs of anterior scleritis?
Sectoral or diffuse redness.
Scleral, episcleral and conjunctival vessels all involved.
Sclera may take on a bluish tinge (best seen on gross examination in natural daylight) ± may be thin and oedematous.
The globe is tender.
Scleromalacia perforans: may be enlarging and coalescing yellow necrotic nodules ± scleral thinning (actual perforation is rare unless intraocular pressure is elevated).
What are the signs of posterior scleritis?
Lid oedema.
Proptosis.
Optic disc swelling.
Retinal detachment can occur.
Which eye conditions is scleritis associated with?
Corneal involvement Glaucoma Uveitis Retinal detachment Cataract formation Rapid onset refractive changes
What are the investigations for scleritis?
In cases of scleritis frequency of association and the severity of these associated problems means that it has to be assumed that there is an underlying cause until proven otherwise.
Every effort should be made to rule out associated pathology.
Depending on clinical suspicion, biochemical tests (eg, FBC and inflammatory markers, rheumatoid screen, syphilis screen), urine dipstick for blood and protein, B-scan ultrasonography of the globe, plain X-rays (chest and sacroiliac joints), MRI or CT imaging (sinuses and orbits) may be indicated.
In a patient with no previously diagnosed systemic disease, it is particularly important to rule out systemic vasculitis, as this is the least likely to have been previously diagnosed and it is a potentially life-threatening disorder.
