Ocular Abnormality- Disorders Of The Sclera & Episclera

Front 1

Name the disorders of the sclera and episclera.

Back 1

• Episcleritis

• Scleritis

• Scleral Discolouration

Front 2

What is the episclera?

Back 2

Covers the sclera

Front 3

Where does the episclera lie?

Back 3

Connective tissue that lies between the superficial scleral stroma and Tenon’s capsule.

Front 4

What does the episclera contain?

Back 4

Contains numerous blood vessels that nourish the sclera

Front 5

What is this?

Back 5

Episcleritis

Front 6

What is episcleritis?

Back 6

Benign, inflammatory condition

• no infection present; so no stringy discharge/pus

• normally idiopathic, infrequently a systemic association exists

Front 7

Who does episcleritis commonly affect?

Back 7

30-40 year olds

Males slightly < F

Front 8

What are the signs of episcleritis?

Back 8

• Acute onset redness, often confined to one area

• 70% of cases are unilateral (unlike conjunctivitis)

• Sometimes no symptoms

• VA usually normal

• Cornea & Anterior Chamber clear

• ES often looks worse than it is!

Front 9

What are the symptoms of episcleritis?

Back 9

• Symptoms vary considerably

• ‘Mild pain’, ‘FB sensation’, ‘Burning’ or ‘Tenderness’

• Photophobia and watery discharge also common

Front 10

What are the 2 types of episcleritis?

Back 10

Simple ES

Modular ES

Front 11

Which type of episcleritis is more common?

Back 11

Simple ES more commonly

Front 12

How can simple episcleritis appear?

Back 12

Can be sectoral (70%) or diffuse (30%)

Front 13

What is this?

Back 13

Simple ES sectoral

Front 14

What is this?

Back 14

Simple ES diffuse

Front 15

How would nodular episcleritis appear?

Back 15

• Translucent white nodule within inflamed area (freely movable)

• More painful than simple ES

• Greater likelihood of systemic involvement

Front 16

What is this?

Back 16

Nodular ES

Front 17

What is the treatment for Episcleritis?

Back 17

• Most cases self-limiting (resolution in 2 or 3 weeks)

• Can use simple lubricants in mild cases

• Topical steroids e.g. prednisolone

• Only effective if used early

• Oral non-steroidal anti-inflammatory agents (NSAIDs) e.g. Flurbiprofen

Front 18

Why would episcleritis reoccur?

Back 18

Systemic involvement?

In particular: inflammatory bowel disease, ulcerative colitis & Crohn’s disease

Front 19

What is Scleritis?

Back 19

• Sclera undergoes inflammation, oedema and sometimes necrosis

• Covers the spectrum of seriousness: may be trivial, self-limiting or a potentially blinding condition

Front 20

Is scleritis common?

Back 20

Much less common than episcleritis

Front 21

What is this?

Back 21

Scleritis

Note there is no limbal flush like anterior uveitis

Front 22

How would scleritis develop?

Back 22

Typically less acute in onset than ES (e.g. develops over days)

Front 23

What would you see with Scleritis?

Back 23

• As well as dilation of scleral vessels, there is also dilation of bulbar conjctiva & episcleral vessels

• Anterior chamber reaction often present

Front 24

What is Scleritis associated with?

Back 24

• Scleritis is associated with systemic collagen disease

• Around 50% of cases have systemic involvement e.g. RA, lupus

Front 25

When can scleritis occur.

Back 25

After glaucoma surgery

Front 26

Who does scleritis affect?

Back 26

• Typically Affects older age group than ES

• Pxs. Typically, 30-60, peak in 40’s.

• F>M (1.6 to 1)

Front 27

What are the signs of Scleritis?

Back 27

• 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

Front 28

What are the symptoms of Scleritis?

Back 28

• 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.

Front 29

What are the 2 types of Scleritis?

Back 29

Anterior scleritis 98%

Posterior scleritis 2%

Front 30

Name the types of anterior scleritis

Back 30

Necrotising 13%

Non necrotising 85%

Front 31

What are the types of non necrotising anterior scleritis.

Back 31

Diffuse

Nodular

Front 32

What would be seen with diffuse non necrotising scleritis?

Back 32

• In diffuse variety, eye is completely reddened (purplish haze)

• Most common type & most benign

• Eye feels very tender

Front 33

What would be seen with nodular non-necrotising anterior Scleritis?

Back 33

• Non-mobile nodules on the surface of sclera

• Nodules correspond to points of focal inflammation & oedema

Front 34

What are the types of necrotising Scleritis?

Back 34

With inflammation

Without inflammation

Front 35

What is Necrotising AS without inflammation: (scleromalacia perfornas)?

Back 35

• Associated with RA

• Insidious and painless “melting” away of the sclera

• Rupture of the globe is possible

Front 36

Describe Necrotising AS with inflammation.

Back 36

• White avascular areas surrounded by areas of scleral reddening

• Ischaemic areas thin over time

Front 37

What is common with Necrotising AS with inflammation?

Back 37

• Anterior Uveitis

• Glaucoma

• Cataract

Front 38

What is posterior scleritis?

Back 38

• Extremely rare but extremely serious

• Painful proptosis & diplopia

• Restriction of eye movements & lid swelling also possible

• Anterior segment may appear normal

Front 39

What happens to the globe with posterior scleritis?

Back 39

Posterior globe flattens

Front 40

What happens to the vision with posterior scleritis?

Back 40

Visual loss usually severe

Front 41

What is the treatment for Scleritis?

Back 41

• 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

• Immuno suppressants prescribed in necrotising scleritis and in PS

• Sometimes also in other forms of the condition when steroids alone don’t work

Front 42

How do you distinguish episcleritis from scleritis?

Back 42

• How quickly did the condition develop

• Ask about systemic conditions

• Blanching technique: instil 2.5% phenlyephrine

• 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

Front 43

What would be seen with the blanching teqnique to distinguish between episcleritis and Scleritis?

Back 43

Episcleral & conj vessels will narrow

Front 44

Why would there be scleral discolouration?

Back 44

Often due to systemic conditions

Front 45

Name the focal scleral discolourations?

Back 45

• 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)

Front 46

What is diffuse scleral discolouration?

Back 46

• Sclera has an overall blue or yellow colour...

• Jaundice (yellowing)

• Conditions that lead to thinning & increased transparency of sclera (blue due underlying uvea)