Scleritis and episcleritis

Question 1

Types of episcleritis

Answer 1

1. simple sectorial
2. simple diffuse
3. Nodular

Question 2

systemic associations of episcleritis

Answer 2

• Rheumatoid arthritis – 11 %
• Inflammatory bowel disease – 8 %
• Vasculitis – 5 %
• Systemic lupus erythematosus – 3 %
• Other rheumatic disease – 3 %
• Herpes zoster ophthalmicus – 3 %
• Lyme disease – 3 %
• Gout

Question 3

Management of episcleritis

Answer 3

1. Cold Compress
2. Topical lubricants
   o 4 to 6 times a day
3. Topical NSAIDs
   o Diclofenac BID or QID
4. Topical steroids
   o Flarex 0.1% QID
   o Pred Forte 1% QID

Refer for systemic work up if indicated

Question 4

How many % of scleritis cases are associated with connective tissue dissorders?

Answer 4

50%

Question 5

Types of scleritis?

Answer 5

Diffuse anterior scleritis: Widespread inflammation of the anterior segment

Nodular anterior scleritis: immovable inflamed nodules

Necrotizing anterior scleritis with inflammation: extreme pain. The sclera becomes transparent because of necrosis. High association with systemic inflammatory disease.

Necrotizing anterior scleritis without inflammation: typically asymptomatic. Seen most commonly is women with long standing rheumatoid arthritis.

Posterior scleritis: May start posteriorly, or rarely be an extension of anterior scleritis, or simulate an amelanotic choroidal mass. Associated with exudative retinal detachment, disc swelling, retinal hemorrhage, choroidal folds, choroidal detachment, restricted motility, proptosis, pain, tenderness.

Question 6

how do I determine avascular areas of the sclera?

Answer 6

red free filter and green light

Question 7

Managment of diffuse and nodular scleritis?

Answer 7

One or more of the following may be required.
Concurrent antacid or histamine type 2 receptor blocker (e.g., ranitidine 150 mg p.o. b.i.d.) is advisable.

● Oral non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line agent for mild-to-moderate scleritis. These consist of non-selective or selective cyclooxygenase inhibitors (COX inhibitors)
● NSAIDs (e.g., ibuprofen 400 to 600 mg p.o. q.i.d.; naproxen 250 to 500 mg p.o. b.i.d.; indomethacin 25 mg p.o. t.i.d.): Three separate NSAIDs may be tried before therapy is considered a failure. If still no improvement, consider systemic steroids.
● Systemic steroids: Prednisone 60 to 100 mg p.o. q.d. for 1 week, followed by a taper to 20mg q.d. over the next 2 to 6 weeks, followed by a slower taper. An oral NSAID often facilitates the tapering of the steroid.

If unsuccessful, consider immunosuppressive therapy.
● Immunosuppressive therapy (e.g., cyclophosphamide, methotrexate, cyclosporine, azathioprine, anti-TNF agents): If one drug is ineffective or not tolerated, additional agents should be tried.
● Systemic steroids may be used in conjunction. Immunosuppressive therapy should be coordinated with an internist or a rheumatologist. The role of topical cyclosporine drops is unclear.

Question 8

Management of necrotizing scleritis?

Answer 8

● Systemic steroid and immunosuppressive therapies are used as above.
Scleral patch grafting may be necessary if there is significant risk of perforation.

Question 9

How do I manage posterior scleritis?

Answer 9

Therapy is controversial and may include systemic aspirin, NSAIDs, steroids, or immunosuppressive therapy as described previously. Consult a retina specialist.

Infectious etiologies: Treat with appropriate topical and systemic antimicrobials. Oral fluoroquinolones have good tissue penetration.

Glasses or eye shield should be worn at all times if there is significant thinning and perforation risk.

Question 10

Can I use topical steriods to manage scleritis?

Answer 10

NOPE!