sclera and epislcera Flashcards
simple episcleritis- symptoms
- Redness
- Discomfort ranges from absent to moderate to very occasionally severe
- Grittiness
- Photophobia may occur
Simple episcleritis signs
- More than half of cases are bilateral
- VA normal
- Redness may be sectoral or diffuse – usually in radial/triangular pattern
Sectoral Diffuse
* Tends to be bright redness as BV nearer surface (good DD for scleritis)
* Chemosis, ocular hypertension, anterior uveitis & keratitis are rare
* If 10% phenylephrine instilled, BV will “blanch” & redness disappears (good DD for scleritis)
simple episcleritis management and prognosis
Management/Prognosis
* Advise px on self-limiting nature
* If mild; no treatment just cold compress or artificial tears for discomfort
* Weak topical steroid 2 x daily for 1-2 weeks is sufficient
* Topical NSAID – alternative to steroid; less effective
* Systemic steroids – rarely used
Episcleritis
- Common
- Usually idiopathic and benign
- Often recurrent
- Usually bilateral
- Rare in children
- Females > males
- Px is usually middle-aged
- Self-limiting – can last from a few days up to 3 weeks
Nodular episcleritis -symptoms
- Redness – noted on waking; over next 2-3 days area of redness enlarges and becomes more uncomfortable
nodular episcleritis signs
- Tender red vascular nodule (raised area)
- With SL section, underlying flat anterior scleral surface should be visible = not scleritis
- IOP may be elevated
- AC reaction possible but uncommon (10% of cases)
- After several episodes, inflamed vessels may become dilated
- BV will blanch with 10% phenylephrine as they do in diffuse episcleritis
nodular episcleritis management
- Same as simple episcleritis but more commonly indicated
- Nodular usually lasts longer – advise px may take 2-3 weeks to clear up
Scleritis general symptoms
- Redness progressing a few days later to pain
- Pain may radiate face & temple
- Ocular tenderness
- Discomfort typically wakes the px in the middle of the night
- Improves as the day goes on
- Pain responds poorly to common analgesics
- Watering
- Photophobia
anterior non necrotising scleritis- diffuse signs
- Hyperaemia may be generalised or localised to one quadrant – loss of radial pattern
- Vascular congestion & dilation associated with oedema
- Secondary features – chemosis, eyelid swelling, anterior uveitis & raised IOP
- As oedema resolves, affected area often takes on grey/blue appearance because of increased scleral translucency
- Will not branch with phenylephrine
Anterior non necrotising scleritis - diffuse prognosis
- Duration of disease is 6 years with frequency of recurrences decreasing after the first 18 months
- Benign
Anterior non necrotising slceritis - nodular signs
- Scleral nodules may be single or multiple
- Most commonly develop close to limbus
- Deeper blue-red colour than episcleral nodules – immobile (cannot be moved)
- SL beam shows elevated anterior scleral surface
- Phenylephrine will not constrict the deep plexus overlying the nodule
Anterior non necrotising scleritis - nodular - prognosis
- Similar to diffuse scleritis (6 years)
- Visual impairment in 25% of cases
- Can develop necrotizing disease
Necrotising scleritis with inflammation - symptoms
- Gradual onset of pan that becomes severe & persistent
- Radiates to the temple, brow or jaw
- Interferes with sleep
- Responds poorly to analgesia
- usually bilateral
Necrotising scleritis with inflammation - signs
- Varies depending on the type/cause
Vaso-occulusive (associated with Rheumatoid arthritis)
Granulomatous
Surgically induced – starts within 3 weeks of procedure (e.g. strabismus, trabeculectomy, scleral buckling for RD, excision of pterygium)
(starts at site of previous surgery)
- Appearance of avascular tissue (blue patch due to death of BV)
- Scleral necrosis & visibility of underlying uvea (blue)
Necrotisiong scleritis without inflammation - symptoms
- Mild non-specific irritation
- Pain is absent
- Vision unaffected
- No dense redness
necrotising scleritis w/out inflammation signs
- Necrotic scleral plaques near the limbus
- No vascular congestion or hyperaemia
- Coalescence and enlargement of necrotic areas
- Slow progression of scleral thinning – yellow colour to blue when underlying uvea exposed
complications accosiated with anterior scleritis
- infiltrative stromal keratitis
- Sclerosing keratitis
- Peripheral ulcerative keratitis
- Uveitis
- Glaucoma
- Perforation of the sclera
- Cataract
management of all anterior scleritis
- Same day/emergency referral – phone eye department of nearest hospital
- Treatment requires oral immunosuppression combined with aggressive topical steroids (high doses)
- Systemic NSAID’s used alone in non-necrotizing disease
- Systemic steroids usually needed in necrotizing disease
- Surgery required for perforation (very rare)
- Prognosis is dependent on underlying disease
- Inflammation is likely to return if due to autoimmune condition (chronic)
- If px got condition due to virus/no underlying systemic disease, then may not return (episodic)
posterior scleritis signs
- Choroidal folds – horizontal
- Exudative retinal detachment occurs in 25% of cases
- Disc oedema & reduced vision (caused by spread of inflammation to orbital tissue and optic nerve)
- Ocular myositis may cause diplopia, pain on movement, tenderness to touch and redness around muscle insertion
- Proptosis
- May have raised IOP
- CT & ultrasound may be required to show increased scleral thickness
posterior scleritis symptoms
- Pain does not correlate with severity of inflammation
- No redness if posterior only but this may be present if anterior scleritis also present (in 40% of cases both present)
- Reduced vision
- More commonly unilateral
infectous scleritis causes
- Herpes Zoster
Most common infective cause
Causes necrotizing scleritis very resistant to treatment - TB – rare & difficult to diagnose
- Leprosy – causes recurrent necrotizing scleritis
- Syphilis – causes diffuse anterior scleritis
- Lyme Disease – scleritis occurs long after initial infection
- Other causes include fungi
Infectous scleritis treatment
- Once infective agent has been identified; specific antimicrobial therapy should be initiated
- Topical & systemic steroids may be needed to reduce inflammatory reaction
