Scleritis Flashcards
What is the aetiology of scleritis?
Causes and associations:
- Systemic associations in ~50% Px
- Infection (in 10-15% of cases)
- Following surgery
Who is scleritis more prevalent in - men or women?
Women
What age group is scleritis more common in?
5th decade so basically your 50s
Is scletitis a bilateral or unilateral condition?
Bilateral in 50% of cases
What are the system associations of scleritis?
-Rheumatoid arthritis
- Wegener Granulamatosis
- Relapsing polychondritis
- Systemic Lupus Erythematosus
- Inflammatory Bowel Disease
- Ankylosing spondylitis
- Polyarteritis nodosa
- Sarcoidosis
- Crohn’s
[basically conditions associated with collagen vascular disease]
What is the case of scleritis caused by infection?
- Herpes Zoster, fungal, bacteria
- Infectious e.g. occurs from spread of infection from corneal ulcer
How can we classifiy scleritis?
By anatomy ( so in this case whether it is anterior (to the extra ocular recti muscles) or posterior (to the insertion of the rectus muscles) ) and whether it presents with inflammation or not.(
What are the SUBJECTIVE clinical charateristics of NON-NECROTISING anterior scleritis?
(so what the patient experiences)
-Red eye
- Unilateral or bilateral
- Reduced VA
- Severe photophobia
- Epiphora
- Pain or severe discomfort
- More gradual onset than episcleritis
What are the OBJECTIVE clincial characteristics of NON-NECROTISING anterior scleritis?
(what the optom looks for)
- 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 (in this case its sight threatening)
- Can occur with inflammation of uvea, cornea etc
- Check posterior involvement
- GH- check for systemic association
How do we assess NON-NECROTISING anterior scleritis?
We are looking for the patient to report that the onset has been gradual over several days.
Could be diffuse or nodular in nature and so we would check for this.
The nodule will not move on palpation ( touch - in this case through pressing on the eyelid). [Different to nodular episcleritis where it does move].
Assess using a slit lamp - looking for the deep scleral vessels which will be involved.
Topical phenylephrine will NOT blanch(whiten) scleral vessels so that’s how we can be sure of scleritis (eye will remain red).
Whats the Plan/Managment for Non-necrotising anterior scleritis?
Refer to ophthalmologist for treatment
They may prescribe the following:
- Topical corticosteroids -E.g. fluorometholone
- Topical NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) - E.g. flurbiprofen 100mg tds or naproxen 500mg bd
What are the SUBJECTIVE clinical characteristics of Necrotising anterior scleritis WITH inflammation?
(i.e. what patient experiences)
- Subacute (this basically means its being an acute situation) (3-4 days) onset
- Severe deep boring pain, radiates to temple, brow, jaw
- Epiphora + photophobia
- Globe very tender to touch
Define acute medically.
present or experienced to a severe or intense degree.
What are the OBJECTIVE clinical characteristics of Necrotising anterior scleritis WITH inflammation?
(i.e. what the optometrist is looking for)
- Congestion of deep vascular plexus
- Vascular occlusion/ distortion
This sesults in avascular + Ischaemic patches thus NECROSIS
• Scleral necrosis (cell death)
-This results in translucency which reveals blue/black uveal tissue below
What is staphyloma?
A staphyloma is an abnormal protrusion of the uveal tissue through a weak point in the eyeball
What are complications associated with necrotising anterior scleritis with inflammation?
- Staphyloma
- Anterior uveitis
- Poor visual prognosis
What is the Plan/managment for Px with Necrotising anterior scleritis with inflammation?
- Refer!
- Oral steroids will be used to treat
-E.g. prednisolone 60- 120mg daily
- Pain relief
- Immunosuppressive (if linked to a systemic cause) -E.g. cyclosporin
What are the SUBJECTIVE clinical characteristics of Necrotising anterior scleritis (without inflammation)?
- Asymptomatic!
- No redness
- No pain
What is necrotising anterior scleritis also known as?
Also known as Scleromalacia perforans
What are the OBJECTIVE clinical characteristics of necrotising anterior scleritis (without inflammation)?
- Yellow necrotic patches in sclera with no inflammation (can be seen in the picture - that yellow circle surrounded by black)
- These yellow necrotic patches Coalesce (means to come together) and progressively expose underlying uvea (this would be the black surrounding the yellow circle)
- Strong association with Rheumatoid Arthritis
[affects females mostly]
Is necrotising anterior scleritis without inflammation normally unilateral or bilateral?
Usually bilateral
What is the Plan/managment for necrotising anterior sclertitis without inflammation?
Refer
- Management of underlying condition
- NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) and steroid therapy
- Enucleation may be required
How can necrotising anterior scleritis result in a BULDGING staphloma?
Sclera thins and underlying uvea becomes visible (this naturally occurs in the condition).
If the IOP is elevated then this results in a BULGING staphyloma.
What are the SUBJECTIVE clinical characteristics of Posterior scleritis?
Mid-severe deep pain (brow or jaw)
- Reduced vision?
- Diplopia?
What are the OBJECTIVE clinical characteristics of Posterior scleritis?
- Range of clinical findings
- White eye
- Lid oedema
- Proptosis, lid retraction, restricted motility
- Disc swelling (can be seen in picture), choroidal folds, macular oedema, exudative retinal detachment
[often misdiagnosed]
What is the Assessment for Posterior Scleritis?
Dilated indirect fundus check
- Ultrasound and look for T sign
- CT scan where you are looking for Posterior scleral thickening
What is the Plan/managment for Posterior Scleritis?
- Refer to ophthalmologist and physician for treatment of systemic association
- In elderly Px - treat underlying systemic association
- In young Px - NSAIDs
