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Episcleritis & Scleritis
This document discusses episcleritis and scleritis. It defines episcleritis as an inflammatory condition affecting the episcleral tissue between the conjunctiva and sclera. Scleritis is characterized by edema and cellular infiltration of the scleral and episcleral tissues. The document classifies episcleritis and scleritis, describes their signs and symptoms, potential causes, diagnostic testing, and treatment options which may include topical or systemic corticosteroids and immunosuppressive medications. Complications are also outlined.
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Episcleritis & Scleritis
- 1. Episcleritis & Scleritis dr.Frenky R. de Jesus National Eye Centre Postgraduate diploma in Ophthalmology
- 2. Episcleritis & Scleritis dr.Frenky DJ Episclera Sclera proper Lamina fusca Thin, dense vascularized layer of connective tissue Fibroblast, macrophages and lymphocytes Avascular structure Dense bundles of collagen fibres Innermost blends with s u p r a c h o r o i d a l a n d supraciliary Presence of pigmented cells. Layers of ScleraScleral
- 3. Episcleritis & Scleritis dr.Frenky DJ Scleral Inflamation Episcleritis Scleritis Nodular Diffuse Anterior Posterior Necrotizing Non- Necrotizing With Inflammation Without Inflammation NodularDiffuse Classification
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- 6. Episcleritis & Scleritis dr.Frenky DJ Episcleritis
- 7. Episcleritis & Scleritis dr.Frenky DJ Definition Episcleritis is an inflammatory condition affecting the episcleral tissue that lies between the conjunctiva and the sclera. It is usually a mild and self-limiting but recurrent disease. Most cases are idiopathic, although up to one third have an underlying systemic condition. Can be divided into: Diffuse and Nodular.
- 8. Episcleritis & Scleritis dr.Frenky DJ • Diffuse episcleritis (84% of cases) is more common than nodular scleritis (16% of cases) • Mean age of all patients with episcleritis is 47.4 years. • Unilateral inflammation is seen in 2/3 of patients with episcleritis. • F>M although the difference is not statistically significant Epidemiology Pathophysiology • Is poorly understood. • The inflammatory response is localized to the superficial episcleral vascular network. • Histopathology shows non- granulomatous inflammation with vascular dilatation and perivascular infiltration.
- 9. Episcleritis & Scleritis dr.Frenky DJ Clinical features History Physical • Acute onset of mild-to-moderate discomfort. • Some may notice only an area of painless injection (unilateral) • Photophobia and watery discharge may be noted. • Clinical findings. • Edema of the episcleral tissue. • Injection of superficial episcleral vessels (Diffuse or Nodule). • The injection in episcleritis blanches (10% phenylephrine). • May be found anterior uveitis and ocular hypertension.
- 10. Episcleritis & Scleritis dr.Frenky DJ Diffuse Scleritis Nodular Scleritis Clinical features • Commonest type • Sectoral /diffuse redness. • Resolves spontaneously in 1 weeks • Localized, raised, congested nodule • Takes longer time to resolve • Sclera not swollen • Sclera appears translucent
- 11. Episcleritis & Scleritis dr.Frenky DJ CAUSES
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- 13. Episcleritis & Scleritis dr.Frenky DJ Phlyctenular Conjunctivitis Scleritis Differential diagnosis
- 14. Episcleritis & Scleritis dr.Frenky DJ Laboratories studies Complete blood count Serum uric acid Rheumatoid factor ESR Venereal Disease Research Laboratory (VDRL) Fluorescent treponemal antibody absorption (FTA-ABS) Antinuclear antibody Chest X-ray
- 15. Episcleritis & Scleritis dr.Frenky DJ Treatment Local therapy • Diffuse episcleritis (no treatment). ✴ Artificial tears ✴ Topical corticosteroids. • Nodular episcleritis ✴ Topical corticosteroids. Systemic therapy • (NSAIDs) ✴ Ibuprofen (400 mg) BID ✴ Flurbiprofen (100 mg) TID ✴ Indomethacin (100 mg) daily ✴ Naproxen (200 mg) QID • Steroids
- 16. Episcleritis & Scleritis dr.Frenky DJ Scleritis
- 17. Episcleritis & Scleritis dr.Frenky DJ Definition Scleritis is a chronic, painful, and potentially blinding inflammatory disease that is characterized by edema and cellular infiltration of the scleral and episcleral tissues (outermost coat of the eye). May be isolated to the eye, but is commonly associated with systemic autoimmune disorders Episcleritis Scleritis Nodular Diffuse Anterior Posterior Necrotizing Non- Necrotizing With Inflammation Without Inflammation NodularDiffuse 98% 2% 15% 85%
- 18. Episcleritis & Scleritis dr.Frenky DJ Disorder immune response Pathophysiology Infectious organisms Endogenous Trauma Autoimmune process Episclera and sclera Perforating capillary and post capillary venules Inflammatory microangipathy Scleritis Inflammation & destruction Causing Damages Lead
- 19. Episcleritis & Scleritis dr.Frenky DJ Anterior Scleritis Anterior non-necrotizing scleritis Presentation • Similar to Episcleritis • More severe discomfort Sign • Relatively benign condition • Wide spread inflammation • Involves a sector or entire sclera • Characteristic distortion of normal radial vascular pattern • High association with HZOunderlying tissue • Nodule can’t be moved over • Intermediate severity impairment • 25% cases having visual 1. Diffuse scleritis 2. Nodular scleritis
- 20. Episcleritis & Scleritis dr.Frenky DJ • Oral NSAIDS:Treatment ✴ Flurbiprofen 100 mg TID ✴ Meloxicam 7.5 mg TID • Oral prednisolone: 40 - 80 mg daily • Combined therapy • Subconjunctival steroid injections: ✴ Triamcinolone acetonide (40mg/ml) ✴ Only for non Anterior non-necrotizing scleritis
- 21. Episcleritis & Scleritis dr.Frenky DJ Clinical features Anterior necrotizing with inflammation • Most severe and distressing form • Bilateral in 60% • Not necessarily simultaneous • There may be associated vascular disease • Mortality rate of 25% within 5 yers of onset Presentation • Gradual onset of pain and localized redness • Pain becomes severe and persistent and radiates to temple, brow or jaw • Frequently interferes with sleep • Responds poorly to analgesia
- 22. Episcleritis & Scleritis dr.Frenky DJ Sign • Associated patches of scleral edema with overlying non perfused episclera and conjunctiva • Patches necrosis. Vaso-occlusive Granulomatous • Start from limbus and extend posteriorly • Within 24 hours involve conjunctiva, episclera and sclera. Treatment • Oral prednisolone: 60 - 120 mg daily 2-3 days • Immunosuppresive agents ✴ Cyclophosphamide ✴ Cyclosporin • Combined therapy ✴ IV methyl-prednisolone
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- 24. Episcleritis & Scleritis dr.Frenky DJ Anterior necrotizing without inflammation Clinical features • Also known as scleromalacia perforans • In women with long standing rheumatoid arthritis • Usually bilateral Treatment Sign • Asymptomatic yellow necrotic patches in uninflammed sclera • Enlargement, spread and coalescence. • Progressive exposure of underlying uvea as a result of scleral thinning. • Staphyloma formation may occur • Spontaneous perforation is rare unless IOP is raised • Is ineffective
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- 26. Episcleritis & Scleritis dr.Frenky DJ Posterior Scleritis • Uncommon, often misdiagnosed. • Affects women twice as often as men. • 1/3 rd patients are under 40 yrs of age at presentation. • Patients over 50 yrs: at increased risk of harbouring systemic disease and suffering visual loss • 2/3 rd cases have unilateral involvement Guarded visual prognosis. • Visual impairment to some degree in 1/3 rd cases. Presentation Sign • Variable • Depends upon exact site of involvement • Most common symptoms are pain and visual impairment External • Lid oedema and fullness • Proptosis and ophthalmoplegia • Associated ant. Scleritis in 1/3 rd cases. Internal • Disc swelling • Macular oedema • Choroidal folds • Exudative retinal detachment • Ring choroidal detachment • Subretinal lipid exudation
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- 28. Episcleritis & Scleritis dr.Frenky DJ Investigations
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- 33. Episcleritis & Scleritis dr.Frenky DJ • Keratopathy - Peripheral corneal thinning, acute stromal keratitis, sclerosing keratitis, interstitial keratitis, punctate keratopathy, or peripheral ulcerative keratitis • Uveitis - Anterior or posterior • Glaucoma • Cataract • Fundus abnormalities - Choroidal folds, subretinal mass, disk edema, macular edema, annular ciliochoroidal detachment, or serous retinal detachment Complications
- 34. Episcleritis & Scleritis dr.Frenky DJ Surgical Care Scleral grafts from fresh donor sclera or glycerin-preserved sclera are available through eye banks. Grafts may be performed in cases of pending perforation during the time before the effects of systemic immunosuppressive agents manifest. Corneal tissue may be used for associated corneal disease. Treatment
- 35. Episcleritis & Scleritis dr.Frenky DJ THANK YOU