Sclera and Episclera (Cale) Flashcards
episclera
loose connective tissue (collagen) b/w sclera (attaches to tenon’s capsule) and conj
superficial episcleral plexus. straight vessels in radial configeration
sclera
high organized collagen, elastin, glycoproteins, proteoglycans. thickest posteriorly, provides rigidity to the globe. Innervated by short and long ciliary
Vascular episclera and sclera
long posterior ciliary and anterior ciliary, superficial vascular plexi, deeper epixcleral plexus adherent to sclera (effected in scleritis), sclera is poorly vascularized
superficial vascular plexi
superficial conj plexus dilates readily and easily slid over underlying tissue. superficial episcleral plexus of larger vessels in radial orientation easily seen when dilated. blanch easily with weak conc of phenylephrin!, anastomose at limbus forming anterior episcleral arterial circle supplying episcleral, ant conj, limbus, iris
episcleritis
simple and nodular
scleritis anterior
non-necrotizing- diffuse and nodular
necrotizing- with inflammation and without inflammation
episcleritis occurence
2/3 have no associated disease- 13% have underlying systemic CT disease. Gender female>male. Young and middle age. No racial predilection. More common in spring and fall
episcleritis presentation
mild transient, recurrent, idiopathic inflammation. typically sectoral but can diffuse (usually interpapebral distribution). often bilateral. symptoms none to moderate (burning, hot discomfort, gritty, photophobia), acute onset. prolonged attacks more likely tied to underlying systemic disease (collagen vascular)
even though there isn’t a treatment what can you do for episcleritis
artificial tears
topical steroid (rebound risk)
topical (maybe no better than placebo) or oral NSAID
–> it’s self limiting so diagnosis is clinical
episcleritis course
Self-limiting 2-21 day course. nodular form more severe taking weeks to resolve
Scleritis
scleritis anterior and posterior
scleritis Angerior
- non-necrotizing (95%): diffuse and nodular
- necrotizing (5%): with inflammation, without inflammation (Scleromalcia perforans)
which is more common scleritis or episcleritis?
episcleritis
Diffuse scleritis presentation
redness followed by aching pain. Intense redness often purplish hue with deep plexus injection. tender to palpation*, lacrimation, photophobia. Bilateral 50% of the time, scleral edema, cornea may be involved. maybe uveitis, chronic destructive inflammation
how do you visualize intense redness of the sclera?
blanching superficial vessels with 2% phenyl
which could cause pt to go blind scleritis or episcleritis?
scleritis
Diffuse scleritis occurance
average onset 45-60yo (Rarely in kids). RARE: prevalence 0.008%. No racial or geographic predilection. Female slightly greater than men, 50% have systemic dz
nodular scleritis
second most common- 20-40% of scleritis pt. female>male. recurrence is common. 20% progress to necrotizing. Disproportionate number have prior HZV of eye. Insidious onset of pain followed by redness, tenderness, nodule
necrotizing scleritis- inflammatory
most severe agressive form and least common. later onset >60yo. female> male. Bilateral 60%. 20% of recurring dodular progress to this. strongest association with systemic dz. can be vision threatening
masqueraders of necrotizing form
malignant melanoma inflammatory syndrome 5%- mainly in form of episcleritis (rarely posterior scleritis). Squamous cell carcinoma of limbus. Atypical course and non-responsive to anti-inflammatory therapy
scleromalacia perforans (necrotizing non-inflammatory)
non-inflammatory, non-perforating–> slow pregression of thinning and exposure of uvea. older females. bilateral frequently. longstanding R.A. Anteriolar occlusion. no treatment
Posterior scleritis
few signs until anterior segment involvement often misdiagnosed, tender to palpation. onset
psoterior scleritis associated complications
papilledema, choroidal folds, CME, retinal heme, exudative RD, choroidal effusion, myositis, proptosis
differentials for posterior scleritis
orbital mass, fundus neoplasm (melanoma), graves Dz, hypotony, uveal effusion syndrome, scleral buckle, rhegmatogenous and exudative RD, Vogt-Koyanagi-Harada dz, orbital cellulitis
scleritis associated disease
most presenting scleritis associated with systemic disease show systemic symptoms as presentation. connective tissue autoimmune. Vasculitides, granulomatous, cutaneous (rosacea), enteropathies (ulcerative colitis, crohns), infectious (HZV)
what should you beware of for scleritis associated disease
concurrent anti-inflammatory tx for these disease masking the signs and symptoms of scleritis
frequency of scleritis w/ systemic Dz
frequency occuring with: RA, inflammatory bowel, wegeners granulomatosis, relapsing polychondritis, SLE, polyarteritis nodosa
clinical workup for scleritis
careful history, SL exam: red free fliter to hi-lite avascular areas, A/C, DFE, B-scan if posterior suspected (MRI, CT), phsyical examination, CBS, FBS, ACE, uric acid
treatment of scleritis
tailored to individual dz and associations, early treatment important, have clearly defined objectives with immuno suppresion (relief of symptoms, preservation of vision, prevention of complications and of treatment complications)
anterior scleritis treatment
6 year relapsing disease
- NSAID (full stomach with H2 receptor blocker, IBU, Naproxen, indomethacin)
- Systemic steroid (prednisone, may facilitate taper with addition of oral NSAID)
- Immunosuppression (methotrexate, cyclophosphamide, cyclosporine, azathioprine, rituximab)
