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21 Cards in this Set
- Front
- Back
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What is the episclera? |
• Covers the sclera • Connective tissue that lies between the superficial scleral stroma and tenon’s capsule. • Contains numerous blood vessels that nourish the sclera |
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Describe episcleritis |
• benign, inflammatory condition • affects 30-40 year olds most commonly • M slightly < F • no infection present; so no stringy discharge/pus • normally idiopathic, infrequently a systemic association exists • patho-physiology is unclear • may involve sectoral drying of conj & underlying episclera |
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What are the signs and symptoms of episcleritis? |
• Acute onset redness, often confined to one area • 70% of cases are unilateral (unlike conjunctivitis) • Symptoms vary considerably • ‘Mild pain’, ‘FB sensation’, ‘Burning’ or ‘Tenderness’ • Photophobia and watery discharge also common • Sometimes no symptoms • VA usually normal • Cornea & Anterior Chamber clear • ES often looks worse than it is |
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What are the two types of episcleritis? |
Simple ES • Can be sectoral (70%) or diffuse (30%) Nodular ES • Translucent white nodule within inflamed area (freely movable) • More painful than simple ES • Greater likelihood of systemic involvement |
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What is the treatment of episcleritis? |
• Most cases self-limiting (resolution in 2 or 3 weeks) • so treatment not usually required • Can use simple lubricants in mild cases • Topical steroids e.g. prednisolone • Only effective if used early • Increased recurrence if topical steroids used? • Oral non-steroidal anti-inflammatory agents (NSAIDs) e.g. Flurbiprofen |
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What can lead to the recurrence of ES? |
• Most cases (~66%) of ES have no systemic involvement • But in severe/recurrent cases, suspect systemic cause • In particular: inflammatory bowel disease, ulcerative colitis & Crohn’s disease |
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What is scleritis? |
• Covers the spectrum of seriousness: may be trivial, self-limiting or a potentially blinding condition • Sclera undergoes inflammation, oedema and sometimes necrosis • Much more severe inflammatory reaction than ES • Much less common than ES • Typically less acute in onset than ES (e.g. develops over days) • More severe and more symptomatic • As well as dilation of scleral vessels, there is also dilation of bulbar conjctiva & episcleral vessels • Anterior chamber reaction often present • Scleritis is associated with systemic collagen disease • Around 50% of cases have systemic involvement e.g. RA, lupus • Can arise after glaucoma surgery • Underlying cause may be infection (e.g. corneal ulcer) • Typically Affects older age group than ES • Pxs. Typically, 30-60, peak in 40’s. • F>M (1.6 to 1) • Uncommon disease (0.08% of HES Px’s) • Two main types: anterior or posterior scleritis |
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What are the signs and symptoms of scleritis? |
• Bilateral in ~50% of cases • Deep purplish ocular injection on presentation • Like ES, it can be segmental or diffuse • VA can be normal or reduced • But VA often reduced in posterior scleritis • Pain (deep, ‘stabbing sensation’), often worse at night • Sometimes pain can be falsely localised (appearing peri-orbital or even temporal) • Photophobia & excessive lacrimation are also common. |
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What are the main types of scleritis? |
• Anterior 98% • Posterior 2% |
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What are the two types of anterior scleritis? |
Anterior Scleitis (AS) divided into necrotising (13%) and non-necrotising (85%) |
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Describe non- necrotising AS? |
• Non-Necrotising AS divided into Diffuse or Nodular • In diffuse variety, eye is completely reddened (purplish haze) • Most common type & most benign • Eye feels very tender |
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Describe non-necrotising AS? |
• Non-mobile nodules on the surface of sclera • Nodules correspond to points of focal inflammation & oedema |
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What are the two types of necrotising AS? |
• Necrotising AS is divided into two types: with inflammation and without |
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Describe necrotising AS without inflammation |
• Necrotising AS without inflammation: (scleromalacia perfornas) • Associated with RA • Insidious and painless “melting” away of the sclera • Rupture of the globe is possible |
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Describe necrotising AS with inflammation |
• White avascular areas surrounded by areas of scleral reddening • Ischaemic areas thin over time • Anterior Uveitis is common, also Glaucoma & Cataract |
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Describe posterior scleritis (PS) |
• Extremely rare but extremely serious • Painful proptosis & diplopia • Restriction of eye movements & lid swelling also possible • Anterior segment may appear normal • Flattening of the posterior aspect of globe • Visual loss in PS usually severe • Can lead to choroidal folds, exudative RD • PS not commonly associated with systemic disorders |
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What is the treatment of scleritis? |
• Refer for medical (systemic association) & ophthalmological investigation • Urgent referral to Ophthalmologist required in necrotising AS and in PS • Topical steroids may be of palliative help only • Oral NSAIDs (e.g. ibuprofen) usually tried first • If inflammation doesn’t respond, systemic steroids tried next • Immunosuppressants prescribed in necrotising scleritis and in PS • Sometimes also in other forms of the condition when steroids alone don’t work • When systemic condition exists, prognosis usually follows course of underlying disease |
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How do we differentiate between scleritis and episcleritis? |
Blanching technique: instil 2.5% phenlyephrine: episcleral & conj vessels will narrow: can assess underlying sclera In ES, vessels radiate posteriorly from limbus. They criss-cross in scleritis Vascular mobility: in ES vessels can be moved over sclera using cotton-tip Nodular mobility: nodular ES versus nodular scleritis |
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Describe scleral discolouration |
• Often due to systemic conditions • Discolouration can be diffuse or focal • Focal Discolouration: • Senile scleral translucency (oval grey areas) • Alkaptonuria (black-brown) • Haemochromatosis (rust-brown) • Metallic foreign body (rust staining) • Systemic Minocycline (blue-grey in para-limbal areas) |
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Describe diffuse scleral discolouration |
• Sclera has an overall blue or yellow colour… • Jaundice (yellowing) • Conditions that lead to thinning & increased transparency of sclera (blue due underlying uvea) • e.g. Turner sydrome |
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Give a summary of episcleritis and scleritis |
• Scleritis & Episcleritis: both cause ‘red eye’ • Episcleritis is relatively common • It’s usually innocuous • Often doesn’t require treatment • Scleritis is rare but potentially very serious • Most cases are Anterior • Systemic associations are common • Can distinguish ES from scleritis using blanching technique • Also use cotton bud to distinguish them |
