scleritis

Question 1

what are the three layers of the sclera?

Answer 1

. episclera
. scleral stroma
. lamina fusca

they are made of collagen and proteoglycans

Question 2

what is scleritis ?

Answer 2

. inflammation of sclera

Question 3

what is the aetiology of scleritis?

Answer 3

. inflammation of the sclera
- oedema and cellular infiltration

. causes and associations:

• systemic association in 50%Px
• following infection
• following surgery

. more frequent in females
. middle age (5th decade)
. bilateral in 50% cases

Question 4

what are the systemic associations of scleritis?

Answer 4

• rheumatoid arthritis
• wegener granulamatosis
• relapsing polychondritis
• systemic lupus erythematosus
• inflammatory bowel disease
• ankylosing spondylitis
• polyarteritis nodosa
• sarcoidosis
• crohn’s

Question 5

explain infection as a cause of scleritis?

Answer 5

. 5-10 % causes get scleritis following an infection
. following herpes zoster, fungal, bacteria
. infectious ( e.g. spread of infection from corneal ulcer)

Question 6

what are the classification of scleritis?

Answer 6

1. anterior (90%)- meaning anterior to the extraocular recti muscles

subdivided into:
1. non-necrotising(75%)
. most cases are diffuse (60%) - where you have redness all over the front eye
. nodular (40%)
2. necrotising (15%)
can occur with inflammation or without inflammation

2. posterior (10%) - meaning posterior to the insertion of the rectus muscles

Question 7

what are the clinical characteristics of non-necrotizing anterior scleritis?
SYMPTOMS

Answer 7

. red eye
- unilateral or bilateral
. reduced VA
. severe photophobia
. epiphora
. pain or severe discomfort
. more gradual onset than episcleritis

Question 8

what is the objective nature of non-necrotizing anterior scleritis?

Answer 8

. deep bluish/purple colour of deeper scleral vessels

. sclera appears oedematous and thin

. inflammatory nodules may be apparent on anterior sclera

. corneal involvement frequent with peripheral thinning ( keratolysis) and deep stromal endothelial disruption

. can occur with inflammation of uvea, cornea

. check posterior involvement

. check for systemic association

Question 9

what is the physical assessment of non-necrotizing anterior scleritis?

Answer 9

. onset gradual over several days
. diffuse
. nodular - nodule will not move on palpation

Question 10

how is the assessment with slit lamp in non-necrotizing anterior scleritis?

Answer 10

. deeper scleral vessel involvement

Question 11

what is the diagnostic test for non-necrotizing anterior scleritis ?

Answer 11

topical phenylephrine 10% will not blanch scleral vessels so eye will appear red

Question 12

what is the plan/ treatment for non-necrotising anterior scleritis ?

Answer 12

. refer to ophthalmologist for treatment

• topical corticosteroids
  e. g. flurometholone
• topical NSAIDs
  e.g. flurbiprofen 100mg
  or naproxen 500mg twice a day
  -systemic steroids
  -Investigation of medication e.g. systemic immunosuppression
  -Imaging for posterior involvement

Question 13

what are the clinical characteristics of necrotising anterior scleritis with inflammation ?
what the px will complain

Answer 13

. subacute (3-4 days) onset
. severe deep boring pain, radiates to temple, brow, jaw 
. epiphora 
. photophobia
. globe will be very tender to touch

Question 14

what is the objective of necrotising anterior scleritis with inflammation?

Answer 14

. congestion of deep vascular plexus

. vascular occlusion/distortion
- results in avascular+ischaemic patches thus necrosis

. scleral necrosis
- translucency reveals blue/black uveal tissue

Question 15

what are the complications of necrotising anterior scleritis with inflammation ?

Answer 15

. staphyloma- abnormal protusion of uveal tissue and they are black in colour
. anterior uveitis

. poor visual prognosis

Question 16

what is the plan of necrotising anterior scleritis with inflammation?

Answer 16

. refer

. oral steroids
e.g. prednisolone 60-120 mg daily
. pain relief

. immunosuppressive

Question 17

what is necrotising anterior scleritis without inflammation known as?

Answer 17

. knowns as scleromalacia perforans

Question 18

what is the subjective of necrotising anterior scleritis without inflammation?

Answer 18

. asymptomatic
. no redness
. no pain

Question 19

what is the objective of necrotising anterior scleritis without inflammation?

Answer 19

. yellow necrotic patches in sclera with no inflammation
. coalesce and progressively expose underlying uvea
. strong association with rheumatoid arthritis
. frequent in females

Question 20

what is the assessment of necrotising anterior scleritis without inflammation?

Answer 20

. quiet eye

. bilateral usually

Question 21

what is the plan of necrotising anterior scleritis without inflammation?

Answer 21

. refer
. management of underlying condition
. NSAIDs and steroid therapy
. enculeation may be required

Question 22

what is the subjective of posterior scleritis ? what the px will complain of?

Answer 22

. mild-severe deep pain
. reduced vision?
. diplopia

Question 23

what is the objective of posterior scleritis? what we will see?

Answer 23

. range of clinical findings
. often misdiagnosed 
. white eye
. lid oedema
. proptosis , lid retraction , restricted motility

. disc swelling, choroidal folds, macular oedema, exudative retinal detachment

Question 24

what is the assessment of posterior scleritis?

Answer 24

. dilated indirect fundus check

. ultrasound
- T sign

. CT scan
. posterior scleral thickening

Question 25

what is the plan of posterior scleritis?

Answer 25

. refer to ophthalmologist and physician for treatment of systemic association

. in elderly PX- treat underlying systemic association

. in young PX - NSAIDs