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Anterior Segment Disease > Sclera and Episclera > Flashcards

Sclera and Episclera Flashcards

1
Q

sclera is ____% of the outer fibrous layer fo the globe

A

85

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2
Q
  • sclera surrounds the globe
  • extends from the ____ anteriorly to the ____ posteriorly
  • merges with the _____
A

limbus;
optic nerve;
dural sheath of the optic nerve

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3
Q

3 layers of the sclera (outer to inner)

A
  • episclera
  • sclera
  • lamina fusca
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4
Q

episclera:

  • thin, outermost region of the sclera
  • inner to ____
  • merges with ____ and ____ 3 mm from the limbus
  • composed of ____
  • highly _____
A

Tenon’s capsule;
Tenon’s capsule; conjunctiva;
loose connective tissue (fibroblasts, collagenous fibers, ground substance);
vascularized (vessels are visible through the transparent conjunctiva

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5
Q

sclera:

  • inner to ____
  • composed of _____
  • collagen type ____ is predominant
  • arrangement of collagen contributes to strength and rigidity and white, opaque color
  • elastin is abundant deeper in the sclera, especially near the rectus muscle insertions and more posteriorly
A

episclera;
thick, dense connective tissue (fibroblasts, collagenous fibers, elastic fibers, ground substance);
1

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6
Q

lamina fusca:

  • innermost aspect of the sclera
  • adjacent to the ____
  • modified ____
  • contains large number of _____ that migrate from the choroid, giving it a _____
A

choroid;
scleral stroma;
melanocytes;
brown color

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7
Q

diameter of sclera for an emmetropic human adult eye:

  • ____ horizontal
  • ____ vertical
  • ____ anteroposterior
A

~24.2 mm;
~23.7 mm;
~22.0-24.8 mm

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8
Q

sclera is thickest _____, decreases in thickness as it approaches _____, thinnest _____, increases in thickness _____, continues to increase in thickness toward the ____

A 
posteriorly near the optic nerve;
the equator of the globe;
under the rectus muscles just before their insertion;
at the muscle insertion site;
limbus
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9
Q

blood supply of sclera:

  • supplied by the ____
  • vessels supplying the recuts muscles continue anteriorly as the _____
  • form the _____ just anteriorly to the rectus muscle insertions
  • capillaries are in the ____
  • ____ is considered avascular (no capillaries)
  • form a superficial and deep ____
  • ____ is mobile
  • ____ is non-mobile
  • both are visible through the transparent conj
A 
episcleral arterial circle;
anterior ciliary arteries;
episcleral arterial circle;
episclera;
sclera;
episcleral plexus;
superficial episcleral plexus;
deep episcleral plexus
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10
Q
  • sclera provides a strong, tough external framework to ____
  • it maintains ____ by offering resistance to ____
  • insertion site for ____
A

protect the delicate intraocular structures;
the shape of the globe;
internal and external forces;
EOMs

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11
Q

____ in the sclera allow nerves and blood vessels to enter and exit the globe

A

apertures and foramen

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12
Q

simple episcleritis

A

inflammation of the episclera involving the superficial episcleral plexus

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13
Q

nodular episcleritis

A

inflammation of the episclera involving the superficial episcleral plexus with an associated nodule

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14
Q

episcleritis etiology/associations

A
  • idiopathic in 60% of cases
  • collagen vascular disease and vasculitis; most common diseases include RA, SLE, GPA, PAN, Behcet’s
  • systemic infection; most common infections include herpes simplex, herpes zoster, lyme, syphilis, TB
  • others (topiramte, rosacea, atopy, gout, sarcoid, IBD, reactive arthritis, ankylosing spondylitis, psoriatic arthritis)
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15
Q

episcleritis demographics

A
  • typically occurs between the ages of 20-40 years

- women > men

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16
Q

episcleritis laterality

A

unilateral or bilateral

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17
Q

episcleritis symptoms

A
  • red eye(s)

- mild eye pain

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18
Q

episcleritis signs

A
  • sectoral episcleral injection; can be diffuse (less common); episcleral vessels are large, course in radial direction, can be moved with a cotton swab and blanch with phenyl
  • some secondary involvement of overlying conj vessels
  • chemosis (edema) in the area of injection
  • mobile nodule in nodular episcleritis
  • rarely, AC rxn (cells/flare) may be present
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19
Q

episcleritis management

A
  • self-limiting within days to weeks; cold compresses and topical lubricants for palliative therapy; mild topical steroid; oral NSAIDs as an alternative to topical steroids (some prefer)- ibuprofen or naproxen
  • if infectious etiology, treat with appropriate anti-infective
  • if bilateral, recurrent, or nodular and etiology is unknown, order lab work based on the most likely etiologies; initial episodes of unilateral simple episcleritis without systemic symptoms do not require lab testing
  • if systemic etiology, refer out for systemic treatment
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20
Q

episcleritis pearls

  • simple episcleritis ____% of cases vs nodular ____%
  • simple episcleritis typically lasts ____ while nodular episcleritis can last ____
  • nodular episcleritis is more likely associated with ____
  • ____ can aid in differentiating between episcleritis and scleritis; instill and reexamine after 10-15 mins; vessels blanch in ____ but not in ____
A 
80; 20
a few days; 
for weeks;
systemic disease;
phenylephrine;
episcleritis;
scleritis
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21
Q

diffuse anterior scleritis

A

inflammation of the anterior sclera involving the deep episcleral plexus

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22
Q

nodular anterior scleritis

A

inflammation of the anterior sclera involving the deep episcleral plexus with an associated nodule

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23
Q

anterior scleritis etiology/associatons

A
  • idiopathic in 40% of cases
  • collagen vascular disease and vasculitis (50% of cases); most common diseases include RA, SLE, GPA, PAN
  • systemic infection; most common infections include herpes simplex, herpes zoster, lyme, syphilis, TB
  • others (e.g., gout, sarcoid, IBD, reactive arthritis, ankylosing spondylitis, psoriatic arthritis)
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24
Q

anterior scleritis demographics

A
  • typically occurs between the ages of 40-60 years

- women > men

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25
Q

anterior scleritis laterality

A

unilateral or bilateral

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26
Q

anterior scleritis symptoms

A
  • red eye(s)
  • severe, deep, boring eye pain; awakens at night; may radiate to adjacent facial regions (forehead, brow, jaw, or sinuses); worsens during eye movement; may have tearing
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27
Q

anterior scleritis signs

A
  • scleral injection; may be sectoral or diffuse; scleral vessels are large, deep vessels that cannot be moved with a cotton swab and do not blanch with phenyl
  • some secondary involvement of overlying episcleral and conj vessels
  • chemosis (edema) in the area of injection
  • sclera is violaceous in color, due to inflammation in deeper tissues
  • immobile nodule in nodular scleritis
  • with recurrent episodes, may see areas of scleral thinning (appears blue-gray)
  • may have an AC rxn
28
Q

anterior scleritis complications

A
  • inflammation of adjacent cornea (peripheral keratitis)

- glaucoma (secondary to increased IOP from increased episcleral venous pressure or trabeculitis)

29
Q

anterior scleritis management

A
  • infectious: treat with appropriate anti-infective
  • non-infectious: oral NSAIDS- naproxen or indomethacin usually, several NSAIDs may be tried before therapy is considered a failure; oral steroids; IV steroids for severe cases; oral immunosuppressants for long-term therapy
  • if etiology is unknown, order lab work based on the most likely etiologies
  • if systemic etiology, refer out for systemic treatment
30
Q

anterior scleritis pearls:

  • most common type of scleritis is ____
  • may last ____
  • ____ is most common systemic association of scleritis
  • violaceous color is best seen in ____
  • if associated with orbital inflammation, may be part of _____
  • usually does not respond to _____
A 
diffuse anterior;
months or years;
RA;
natural light by gross inspection
orbital pseudotumor;
topical therapy (Durezol has been shown to work in mild cases)
31
Q

anterior necrotizing scleritis w/ inflammation

A

severe form of anterior scleritis with associated necrosis

32
Q

anterior necrotizing scleritis w/ inflammation etiology/associations

A
  • collagen vascular disease and vasculitis; most common diseases include RA, SLE, GPA, PAN
  • systemic infection; most common infections include herpes simplex, herpes zoster, lyme, syphilis, TB
  • others (e.g., gout, sarcoid, IBD, reactive arthritis, ankylosing spondylitis, psoriatic arthritis)
33
Q

anterior necrotizing scleritis w/ inflammation demographics

A
  • typically occurs between the ages of 40-60 years

- women > men

34
Q

anterior necrotizing scleritis w/ inflammation laterality

A

unilateral or bilateral

35
Q

anterior necrotizing scleritis w/ inflammation symptoms

A
  • red eye(s)
  • extreme pain; awakens the patient at night; may radiate to adjacent facial structures (forehead, brow, jaw, or sinuses); worsens during eye movement; may have tearing
36
Q

anterior necrotizing scleritis w/ inflammation signs

A
  • anterior scleritis progresses to isolated patches of scleral edema with overlying non-perfused episclera and conjunctiva (appears white); patches can coalesce and rapidly proceed to progressive scleral necrosis (appears blue-gray)
  • may have an AC rxn
37
Q

anterior necrotizing scleritis w/ inflammation complications

A
  • inflammation of the adjacent cornea (peripheral keratitis)
  • glaucoma (secondary to increased IOP from increased EVP or trabeculitis)
  • scleral perforation
38
Q

anterior necrotizing scleritis w/ inflammation management

A
  • infectious: treat with appropriate anti-infective
  • non-infectious: oral steroids, IV steroids for severe cases, oral immunosuppressants for long-term therapy
  • if etiology is unknown, order lab work based on the most likely etiologies
  • if systemic etiology, refer out for systemic treatment
  • recommend glasses or eye shield for protection
  • if scleral perforation occurs, refer out for surgery- scleral patch graft
39
Q

anterior necrotizing scleritis w/ inflammation pearls:

-if associated with rheumatoid arthritis, associated with ____

A

increased mortality due to coronary arteritis or cerebral angiitis

40
Q

anterior necrotizing scleritis w/o inflammation (scleromalacia perforans)

A

necrosis of the anterior sclera

41
Q

anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) etiology/associations

A

high association with RA

42
Q

anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) demographics

A
  • typically occurs between ages of 40-60 years

- women > men

43
Q

anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) laterality

A

unilateral or bilateral

44
Q

anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) symptoms

A

no to minimal symptoms

45
Q

anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) signs

A

necrotic scleral plaques (appears blue-gray) near the limbus without surrounding inflammation

46
Q

anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) complications

A

scleral perforation

47
Q

anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) management

A
  • oral steroids
  • IV steroids for severe cases
  • oral immunosuppressants for long-term therapy
  • if etiology is unknown, order lab work based on the most likely etiologies
  • if systemic etiology, refer out for systemic treatment
  • recommend glasses or eye shield for protection
  • if scleral perforation occurs, refer out for surgery- scleral patch graft
48
Q

anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) pearls:

  • rare, only ____% of scleritis
  • if associated with rheumatoid arthritis, associated with _____
A

4;

increased mortality due to coronary arteritis or cerebral angiitis

49
Q

anterior necrotizing scleritis w/o inflammation (scleromalacia perforans): other etiologies for a blue-gray sclera

A
  • age-related scleral thinning (usually near recti muscle insertions)
  • genetic defect in collagen synthesis (ex: Ehler’s Danlos, osteogenesis imperfecta)
  • drug toxicity (ex: minocycline)
  • Axenfeld loop (long ciliary nerve that courses anteriorly through the sclera before looping back to course to the ciliary body)
  • oculo(dermal) melanocytosis
50
Q

posterior scleritis

A

inflammation of the posterior sclera (posterior to insertion of rectus muscles)

51
Q

posterior scleritis etiology/associations

A
  • idiopathic
  • collagen vascular disease and vasculitis; most common diseases include RA, SLE, GPA, PAN
  • systemic infection; most common infections include herpes simplex, herpes zoster, lyme, syphilis, TB
  • others (e.g., gout, sarcoid, IBD, reactive arthritis, ankylosing spondylitis, psoriatic arthritis)
52
Q

posterior scleritis demographics

A
  • typically occurs between the ages of 40-60 years

- women > men

53
Q

posterior scleritis laterality

A

unilateral > bilateral

54
Q

posterior scleritis symptoms

A
  • minimal to no eye redness
  • severe, boring eye pain; awakens the patient at night; may radiate to adjacent facial regions (forehead, brow, jaw, or sinuses); worsens during eye movement; may have tearing
  • blurred vision
55
Q

posterior scleritis signs

A
  • chorioretinal folds
  • proptosis
  • restricted motility
  • hyperopia (sometimes will see an increase)
  • peripapillary T sign on B scan- fluid between Tenon’s capsule and sclera creates a squaring off of the interface between the ON and sclera
56
Q

posterior scleritis complications

A
  • choroidal detachment
  • retinal pathology (hemes, exudative RD, CME)
  • optic disc edema
  • glaucoma (secondary to increased IOP from increased EVP, trabeculitis, angle closure)
57
Q

posterior scleritis management

A
  • infectious: treat with appropriate anti-infective
  • non-infectious: oral NSAIDS (several may be tried before therapy is considered a failure), oral steroids, IV steroids for severe cases, oral immunosuppressants for long-term therapy
  • if etiology is unknown, order lab work based on the most likely etiologies
  • if systemic etiology, refer out for systemic treatment
58
Q

posterior scleritis pearls:

  • posterior scleritis occurs ______ frequently than anterior scleritis
  • rarely, an extension of _____
A

much less;

anterior scleritis

59
Q

jaundice (hyperbilirubinemia)

A

excessive bilirubin (orange-yellow pigment) in the blood

60
Q

jaundice (hyperbilirubinemia) etiology/associations

A
  • liver dysfunction (bilirubin is metabolized by the liver so it can be excreted in urine and stool)
  • bile duct obstruction (bile, a fluid produced by the liver, is transported through ducts directly to the small intestine to help digest fats, bilirubin is a component of bile)
  • hemolytic anemia (excessive breakdown of RBCs)(bilirubin is produced during normal breakdown of RBCs)
61
Q

jaundice (hyperbilirubinemia) demographics

A
  • depends on etiology

- newborn to adult

62
Q

jaundice (hyperbilirubinemia) laterality

63
Q

jaundice (hyperbilirubinemia) symptoms

A

yellow discoloration of the eyes and skin

64
Q

jaundice (hyperbilirubinemia) signs

A
  • sclera icterus (diffuse yellowing of the sclera)

- yellowing of the skin starting from the head down

65
Q

jaundice (hyperbilirubinemia) management

A

refer out for systemic treatment

66
Q

jaundice (hyperbilirubinemia) pearls:

  • affects ____% of term newborns and ___% of premature babies
  • due to _____
  • usually resolves by the first week of life
A

60; 80;

immaturity of the liver or decreased elimination of urine and stool (due to difficulty with breastfeeding)

Anterior Segment Disease (22 decks)

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