Sclera and Episclera (Cale)

Question 1

episclera

Answer 1

loose connective tissue (collagen) b/w sclera (attaches to tenon’s capsule) and conj
superficial episcleral plexus. straight vessels in radial configeration

Question 2

sclera

Answer 2

high organized collagen, elastin, glycoproteins, proteoglycans. thickest posteriorly, provides rigidity to the globe. Innervated by short and long ciliary

Question 3

Vascular episclera and sclera

Answer 3

long posterior ciliary and anterior ciliary, superficial vascular plexi, deeper epixcleral plexus adherent to sclera (effected in scleritis), sclera is poorly vascularized

Question 4

superficial vascular plexi

Answer 4

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

Question 5

episcleritis

Answer 5

simple and nodular

Question 6

scleritis anterior

Answer 6

non-necrotizing- diffuse and nodular

necrotizing- with inflammation and without inflammation

Question 7

episcleritis occurence

Answer 7

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

Question 8

episcleritis presentation

Answer 8

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)

Question 9

even though there isn’t a treatment what can you do for episcleritis

Answer 9

artificial tears
topical steroid (rebound risk)
topical (maybe no better than placebo) or oral NSAID
–> it’s self limiting so diagnosis is clinical

Question 10

episcleritis course

Answer 10

Self-limiting 2-21 day course. nodular form more severe taking weeks to resolve

Question 11

Scleritis

Answer 11

scleritis anterior and posterior

Question 12

scleritis Angerior

Answer 12

• non-necrotizing (95%): diffuse and nodular

- necrotizing (5%): with inflammation, without inflammation (Scleromalcia perforans)

Question 13

which is more common scleritis or episcleritis?

Answer 13

episcleritis

Question 14

Diffuse scleritis presentation

Answer 14

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

Question 15

how do you visualize intense redness of the sclera?

Answer 15

blanching superficial vessels with 2% phenyl

Question 16

which could cause pt to go blind scleritis or episcleritis?

Answer 16

scleritis

Question 17

Diffuse scleritis occurance

Answer 17

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

Question 18

nodular scleritis

Answer 18

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

Question 19

necrotizing scleritis- inflammatory

Answer 19

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

Question 20

masqueraders of necrotizing form

Answer 20

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

Question 21

scleromalacia perforans (necrotizing non-inflammatory)

Answer 21

non-inflammatory, non-perforating–> slow pregression of thinning and exposure of uvea. older females. bilateral frequently. longstanding R.A. Anteriolar occlusion. no treatment

Question 22

Posterior scleritis

Answer 22

few signs until anterior segment involvement often misdiagnosed, tender to palpation. onset

Question 23

psoterior scleritis associated complications

Answer 23

papilledema, choroidal folds, CME, retinal heme, exudative RD, choroidal effusion, myositis, proptosis

Question 24

differentials for posterior scleritis

Answer 24

orbital mass, fundus neoplasm (melanoma), graves Dz, hypotony, uveal effusion syndrome, scleral buckle, rhegmatogenous and exudative RD, Vogt-Koyanagi-Harada dz, orbital cellulitis

Question 25

scleritis associated disease

Answer 25

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)

Question 26

what should you beware of for scleritis associated disease

Answer 26

concurrent anti-inflammatory tx for these disease masking the signs and symptoms of scleritis

Question 27

frequency of scleritis w/ systemic Dz

Answer 27

frequency occuring with: RA, inflammatory bowel, wegeners granulomatosis, relapsing polychondritis, SLE, polyarteritis nodosa

Question 28

clinical workup for scleritis

Answer 28

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

Question 29

treatment of scleritis

Answer 29

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)

Question 30

anterior scleritis treatment

Answer 30

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)