Sclera & Episclera

Question 1

What arteries vascularize the episclera?

Answer 1

Long posterior ciliary & anterior ciliary (along recti)

Superficial Conjunctival plexus

Superficial episcleral plexus

The plexi anastomose at limbus forming anterior episcleral arterial circle

Question 2

What vasculature is affected in scleritis?

Answer 2

Deeper episcleral plexus which is adherent to the sclera

Question 3

Is the sclera vascularized?

Answer 3

It is pooly vascularized

Question 4

What percent of scleritis is non-necrotizing?

Answer 4

95%

Question 5

What percent of episcleritis occurance is idiopathic?

Answer 5

2/3

Question 6

What demographics are more likely to get episcleritis?

Answer 6

Female > male

Young and middle aged

No racial predilection

More common in spring and fall

Question 7

How does episcleritis present?

Answer 7

Bilateral

Burning, hot discomfort, gritty, photophobia

Pain more likely in nodular

Acute onset

Typically sectoral but can be diffuse

Question 8

How do you treat episcleritis?

Answer 8

Episcleritis is limiting at about a 21 day course. Nodular episcleritis is on the longer end.

Usually no treatment but may use: Artificial Tears, Topical Steroids, Topical or Oral NSAIDs

Question 9

Why are topical steroids risky?

Answer 9

Rebound

Question 10

Answer 10

Nodular Episcleritis

Question 11

Answer 11

Nodular Episcleritis

Question 12

What percent of non-necrotizing scleritis is nodular?

Answer 12

5%

Question 13

How does diffuse scleritis present?

Answer 13

Redness followed by aching and deep boring pain

Superior temporal quadrant start

Intense redness/purplish hue w/ deep plexus injection

Tender to palpation

Bilateral (50% of time)

Chronic inflammation

Lacrimation, Photophobia

Question 14

Answer 14

Diffuse scleritis

Question 15

How often is the cornea involved in diffuse scleritis?

Answer 15

30%

Question 16

What is the occurence of diffuse scleritis?

Answer 16

Average onset 45-60yo

RARE

No racial or geographic predilection

Female slightly greater than male

50% have underlying systemic dz

Question 17

Answer 17

Diffuse Scleritis

Question 18

What happens in scleral thinning?

Answer 18

Underlying dark uveal pigment becomes visible

Question 19

What is the second most common form of scleritis?

Answer 19

Nodular scleritis; 20-40% of patients

Question 20

What is the occurence of nodular scleritis?

Answer 20

Female > male

Recurrence common

Disproportionate number have prior HZV of eye

Question 21

What percent of nodular scleritis progresses to necrotizing?

Answer 21

20%

Question 22

Answer 22

Nodular Scleritis

Question 23

Answer 23

Nodular scleritis; notice displacement of beam over nodule

Question 24

What is the most severe and least common form of scleritis?

Answer 24

Necrotizing scleritis

Question 25

What is the presentation and occurence of necrotizing scleritis?

Answer 25

**Later onset (\>60yo)** **Female \> male** **Bilateral 60%** **Strongest association with systemic dz**

Question 26

What form of scleritis is vision threatening?

Answer 26

Necrotizing scleritis

Question 27

What are some diseases that may masquerade as necrotizing scleritis?

Answer 27

Malignant melanoma inflammatory syndrome Squamous cell carcinoma of limbus If there is an atypical course and it is non-responsive to anti-inflammatory therapy then you should **biopsy**.

Question 28

What is the presentation of scleromalacia perforans?

Answer 28

Non-inflammatory, non-perforating Older females Bilateral Longstanding RA Arteriolar occlusion

Question 29

What is the treatment for scleromalacia perforans?

Answer 29

There is none.

Question 30

Answer 30

Non inflammatory Scleromalacia Perforans

Question 31

Why is posterior scleritis so dangerous?

Answer 31

Has few anterior signs making it often misdiagnosed Pain is not as severe as the orbital inflammation looks like it should be Blindness can occur quickly

Question 32

What are some differentials to posterior scleritis?

Answer 32

Orbital mass Fundus neoplasm Graves Dz Hypotony Scleral buckle Orbital cellulitis

Question 33

What systemic diseases are most commonly associated with scleritis?

Answer 33

Inflammatory bowel dz (18%) Relapsing polychondritis (40%)

Question 34

How should you treat scleritis?

Answer 34

Each treatment should be handled individually and early treatment is important Must have clearly defined objectives with immunosuppression: Relief of symptoms Preservation of vision Prevention of complications Prevention of treatment complications

Question 35

Answer 35

Peripheral ulcertive keratitis