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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
anterior scleritis laterality
unilateral or bilateral
26
anterior scleritis symptoms
- 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
27
anterior scleritis signs
- 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
anterior scleritis complications
- inflammation of adjacent cornea (peripheral keratitis) | - glaucoma (secondary to increased IOP from increased episcleral venous pressure or trabeculitis)
29
anterior scleritis management
- 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
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 _____
``` 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
anterior necrotizing scleritis w/ inflammation
severe form of anterior scleritis with associated necrosis
32
anterior necrotizing scleritis w/ inflammation etiology/associations
- 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
anterior necrotizing scleritis w/ inflammation demographics
- typically occurs between the ages of 40-60 years | - women > men
34
anterior necrotizing scleritis w/ inflammation laterality
unilateral or bilateral
35
anterior necrotizing scleritis w/ inflammation symptoms
- 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
anterior necrotizing scleritis w/ inflammation signs
- 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
anterior necrotizing scleritis w/ inflammation complications
- inflammation of the adjacent cornea (peripheral keratitis) - glaucoma (secondary to increased IOP from increased EVP or trabeculitis) - scleral perforation
38
anterior necrotizing scleritis w/ inflammation management
- 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
anterior necrotizing scleritis w/ inflammation pearls: | -if associated with rheumatoid arthritis, associated with ____
increased mortality due to coronary arteritis or cerebral angiitis
40
anterior necrotizing scleritis w/o inflammation (scleromalacia perforans)
necrosis of the anterior sclera
41
anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) etiology/associations
high association with RA
42
anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) demographics
- typically occurs between ages of 40-60 years | - women > men
43
anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) laterality
unilateral or bilateral
44
anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) symptoms
no to minimal symptoms
45
anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) signs
necrotic scleral plaques (appears blue-gray) near the limbus without surrounding inflammation
46
anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) complications
scleral perforation
47
anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) management
- 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
anterior necrotizing scleritis w/o inflammation (scleromalacia perforans) pearls: - rare, only ____% of scleritis - if associated with rheumatoid arthritis, associated with _____
4; | increased mortality due to coronary arteritis or cerebral angiitis
49
anterior necrotizing scleritis w/o inflammation (scleromalacia perforans): other etiologies for a blue-gray sclera
- 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
posterior scleritis
inflammation of the posterior sclera (posterior to insertion of rectus muscles)
51
posterior scleritis etiology/associations
- 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
posterior scleritis demographics
- typically occurs between the ages of 40-60 years | - women > men
53
posterior scleritis laterality
unilateral > bilateral
54
posterior scleritis symptoms
- 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
posterior scleritis signs
- 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
posterior scleritis complications
- choroidal detachment - retinal pathology (hemes, exudative RD, CME) - optic disc edema - glaucoma (secondary to increased IOP from increased EVP, trabeculitis, angle closure)
57
posterior scleritis management
- 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
posterior scleritis pearls: - posterior scleritis occurs ______ frequently than anterior scleritis - rarely, an extension of _____
much less; | anterior scleritis
59
jaundice (hyperbilirubinemia)
excessive bilirubin (orange-yellow pigment) in the blood
60
jaundice (hyperbilirubinemia) etiology/associations
- 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
jaundice (hyperbilirubinemia) demographics
- depends on etiology | - newborn to adult
62
jaundice (hyperbilirubinemia) laterality
bilateral
63
jaundice (hyperbilirubinemia) symptoms
yellow discoloration of the eyes and skin
64
jaundice (hyperbilirubinemia) signs
- sclera icterus (diffuse yellowing of the sclera) | - yellowing of the skin starting from the head down
65
jaundice (hyperbilirubinemia) management
refer out for systemic treatment
66
jaundice (hyperbilirubinemia) pearls: - affects ____% of term newborns and ___% of premature babies - due to _____ - usually resolves by the first week of life
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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