Inflammatory disease

Question 1

Why does the body inflame?

Answer 1

• Catalyses flow of beneficial components (nutrients, oxygen)
• Facilitates transport of immune cells
- Neutralise invading microbes
- Initiate tissue repair

Timeline:
1. Brief vasoconstriction
2. Vasodilation
3. Increased blood vessel permeability
4. Tissue repair and scarring

Question 2

Vasodilation:

Answer 2

• Increases blood flow to affected tissue
• Redness (Rubor) due to increased blood flow
• Raised temperature (Calor)

Question 3

Increased blood vessel permeability:

Answer 3

• Fluid escapes from blood vessel
• Accumulates in surrounding tissue- swelling (Tumor)
• Swelling stimulates sensory nerves- pain (Dolor)

Oedema = Swelling

Question 4

What is the episclera?

Answer 4

• Thin layer of connective tissue between bulbar conjunctival and sclera
• Outermost layer of the sclera
• Transparent, but embedded network of fine blood vessels

Question 5

Episcleritis:

Answer 5

• Inflammation of episcleral tissue
• Common, most often affects younger adults (30-50 years old)
• Recurrent “Have you ever had anything like this before”
• Most cases are idiopathic
• Minority (<30%) associated with systemic inflammatory disease
- Rheumatoid arthritis
- Systemic lupus
- Inflammatory bowel disease

Question 6

Episcleritis - Symptoms

Answer 6

• Acute (sudden) onset (last day or two)
• Majority unilateral, although can be bilateral
• Redness often chief complaint
• Mild discomfort
• No pain (lack of sensory nerve endings in episclera)
• Vision unaffected

Question 7

Simple episcleritis - Signs

Answer 7

• Hyperaemia
• Vasodilation
• Bright red blood vessels
• May be sectoral- confined to area
• Or diffuse (widespread)

Question 8

Nodular episcleritis - Signs

Answer 8

• Minority of cases (approx. 20%)
• Raised lump within area of hyperaemia
• Conjunctiva bulges forward
• Displaces slit lamp beam

Question 9

Episcleritis - Management

Answer 9

• Self-limiting condition
• Reassure: not sight-threatening, will resolve in 1-2 weeks
• Caution: recurrent condition
• Cold compresses : Promotes vasoconstriction
• Discomfort : Artificial tears for 1-2weeks

Question 10

Episcleritis - Management: Beyond entry level (IP)

Answer 10

Anti-inflammatory medications:
• Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• Topical Steroids

• Systemic (Oral) NSAIDs

Question 11

Scleritis:

Answer 11

• Severe inflammatory disease of sclera
• Relatively uncommon
• 40-60 years old
• M:F ratio = 2:3
• Some cases are idiopathic
• Stronger systemic association than episcleritis
• May be first sign of systemic disease

Question 12

Scleritis - Symptoms:

Answer 12

Unilateral, but up to 50% cases bilateral
• Redness
• PAIN
- Moderate-severe
- Interferes with sleep
- Radiates to temple and brow
- Minimal relief with over-the-counter analgesics
- Worse on eye movement and with touch

• Gradual onset- develops slowly, over a few days
• Epiphora
• Vision may be affected

Question 13

Types of scleritis:

Answer 13

Anterior Scleritis (90%)
• Non-Necrotising (75%)
> Diffuse (60%)
> Nodular (40%)

• Necrotising (15%)
> With inflammation
> Without inflammation

• Posterior scleritis (10%)

Question 14

Anterior scleritis: Non-Necrotising (75%); Diffuse (60%)

Answer 14

• Hyperaemia
• Rich, deep red colour (with purplish hue)
• Always measure monocular VA
• Best prognosis, lowest risk of permanent visual impairment

Question 15

Anterior scleritis: Non-Necrotising (75%); Nodular (60%)

Answer 15

• Hyperaemia
• Rich, deep red colour (with purplish hue)
• Fixed nodule

Question 16

How to determine if its scleritis or episcleritis?

Answer 16

• Phenylephrine (2.5% or 10%) + 5 minutes
- Sympathomimetic (Mydriatic- iris dilator muscle)
- Vasoconstrictor: superficial conjunctival/episcleral vessels

• If redness blanches - episcleritis (or conjunctivitis)
• If redness persists - scleritis
• Also: Check VA (episcleritis does not reduce VA)

Question 17

Anterior Scleritis: Necrotising with inflammation; Signs

Answer 17

• Necrosis: premature tissue death due to injury or disease
• Aggressive and severe
• Hyperaemia- rich, deep red colour (with purplish hue)
• Patches of avascular tissue
• Progressive scleral thinning
• Exposes underlying uvea (dark blue-grey tinge)

Question 18

Anterior Scleritis: Necrotising without inflammation;
Signs

Answer 18

• Scleromalacia Perforans
• Females with rheumatoid arthritis
• No hyperaemia
• Often asymptomatic- no pain!

Question 19

Describe Posterior scleritis

Answer 19

• No visible redness
• Moderate-to-severe pain
• Vision: loss or distortion

Dilated funds examination:
• Choroidal folds

• Advanced imaging (ultrasound, CT scan)
• Up to 40% also have anterior scleritis

Question 20

Scleritis - Management

Answer 20

• Emergency referral (same day) to Ophthalmologist
• Emphasise urgency- best outcome with early treatment
• Systemic investigations

Anti-Inflammatory Medications:
• Topical Steroids
e.g. Prednisolone acetate (1%) Pred Forte
• Systemic (Oral) NSAIDs
e.g. Flurbiprofen (100mg)
• Systemic Steroids
e.g. Prednisolone (oral tablets)

Question 21

Uvea:

Answer 21

• Iris
• Ciliary Body
• Choroid

Question 22

Types of uveitis:

Answer 22

• Anterior Uveitis: Iris and (anterior) Ciliary Body
• Intermediate Uveitis: (posterior) Ciliary Body, Anterior Vitreous, Peripheral Retina/ Choroid
• Posterior Uveitis: Vitreous and Retina Choroid
• Panuveitis: All uvea

Question 23

Anterior uveitis:

Answer 23

• Iritis and Iridocyclitis
• Most common sub-type: 75% of cases
• Not uncommon: 12 per 100,000 people per year
• Mean age: 40 years old
• Many cases are idiopathic (approx. 50%)
• Associated with systemic inflammatory diseases

Question 24

Anterior uveitis: Symptoms

Answer 24

• Generally unilateral
• Pain
- Aching, dull, throbbing, Sudden onset (first episode)
• Recurrent disease
• Photophobia; light or near work
• Miosis
• Redness
• Reduced vision (depends on severity)
• Lacrimation

Question 25

Anterior uveitis : Signs

Answer 25

• Hyperaemia
• Circumlimbal flush (around limbus)
• Miosis

•Aqueous cells
- Seen with conical beam
• Aqueous flare
• Reduced VA - due to debris in aqueous
• Hypopyon
• Keratic precipitates

Question 26

Anterior uveitis : Complications

Answer 26

• Posterior synechiae
- Cells/flare and pupil miosis
- disrupts normal flow of aqueous humour
• Secondary glaucoma

Question 27

Anterior uveitis associated glaucoma types:

Answer 27

• Secondary Angle Closure Glaucoma
- Posterior synechiae
- Raised IOP
• Secondary Open angle glaucoma
- Inflammatory debris ‘clogs-up’ trabecular meshwork
- Reduces aqueous humour outflow
- Raised IOP

Question 28

Intermediate uveitis is the inflammation of:

Answer 28

• Posterior ciliary body
• Anterior vitreous
• Periolherall choroid/retina

Question 29

Intermediate uveitis: Symptoms

Answer 29

• Reduced vision
Gradual- over a few days
• Floaters
Vitreous inflammation, Sharp rise in number of floaters, Compare eyes if unilateral disease

Question 30

Intermediate uveitis: Signs

Answer 30

• Reduced VA
- Inflammatory debris, cystoid macular edema
• Vitritis
- Inflammatory cells in humour, Flare
•Snowballs
- Yellow/white fluffy collections, inferior due to gravity
• Snowbanking
- white/grey plaques, accumulation of snowballs

Question 31

Posterior uveitis: Inflammation of..

Answer 31

• Vitreous
• Choroid
• Retina

Question 32

Posterior uveitis: symptoms

Answer 32

• Reduced vision
- Gradual, over a few days
• Floaters

Question 33

Posterior uveitis: Signs

Answer 33

• Reduced VA
- Inflammatory debris, Cystoid Macular edema
• Vitritis
- Inflammatory cells in vitreous humour, flare
• Choroiditis
- Yellow patches, active inflammation fuzzy; inactive- pigmented, well defined
• Retinitis
- Indistinct, fluffy patches, cloud like
• Vasculitis

Question 34

Management of all types of uveitis: treatment

Answer 34

All types or uveitis are sight threatening:
• Measure IOP
• Carry out dilated fundus exam

• Mydriatic drug, cyclopentolate (3x for up to 7 days)
- Reduces risk of posterior synechiae, may break if formed
- relaxes sphincter/ciliary muscles relieving spasm and associated pain
- sunglasses for photophobia

Question 35

Management of all types of uveitis: referral

Answer 35

• Sight threatening disease
• Urgent referral (telephone call to Hospital)

Treatment:
1. Mydriatic
2. Steroid
• Anti-inflammatory drug, inhibits inflammatory response
• High potency (powerful) steroids needed to bring inflammation under control:

• Prednisolone acetate (1%), 1 drop every hour for first 2-3 days
• Dexamethasone (0.1%), 1 drop every hour for first 2-3 days

Question 36

Uveitis management: Ophthalmology and IP

Answer 36

• Ophthalmology: Investigate for associated systemic inflammatory disease
- Particularly important if recurrent

• For intermediate and posterior uveitis:
- Topical steroids unlikely to reach sufficient concentration in vitreous/retina
> Injection (intraocular steroid)
> Systemic (oral tablet)