Anterior Segment 2: Lecture 1 Disorders of the Episclera and Sclera

Episclera

fibroelastic structure found inn between the sclera and conjuntiva

Two layers of the episclera

- Outer Parietal Layer

- Deep Visceral Layer

Outer parietal layer contains

superficial episcleral capillary plexus

Deep visceral layer contains

deep episcleral capillary plexus

Sclera

tough white outer layer of the eye for structural support and protection

3 layers of the sclera

episclera

scleral stroma

lamina fusca

Superficial episcleral layer functions

nutritional support for outer sclera

immune surveillance and response for vascularity

site of superficial vascular plexus

Deep episcleral layer

- anchor between episclera and sclera

- barrier and forms integrity

- site of deep vascular plexus

The stroma functions

protective barrier

attatchment site for EOMs

"Episcleritis"

Inflammation of episclera

"scleritis"

inflammation of the sclera

Episcleritis

an inflammation of the superficial episcleral vessels

Episcleritis etiology

most found in younger/middle aged patients

Women>men

about 2/3rd of Episcleritis cases are

idiopathic ******

Episcleritis: pathophysiology

a non granulomatous inflammation with vascular dilation and perivascular infiltration of lymphocytes and plasma cells

Episcleritis: Signs and symptoms

mild pain or foreign body sensation "prickly feeling"

*acute redness and mild pain in one or both eyes*

sectoral or diffuse injection

possible mobile nodule

Classifications of episcleritis

Simple or Nodular

Simple Episcleritis

-acute

- more common

- sectoral or diffuse

- absence of nodule

- mild discomfort or asymptomatic

(less pain and no nodule)

Nodular Episcleritis

- gradual course

- discrete and elevated area (nodule)

- MORE PAINFUL

Evaluation of Episcleritis

Full ocular eval with DFE

1. determine of simple vs nodular

2. use Phenylephrine 2.5% and 10% test

3. Check for presence of cells and flare

How do we tell of its Episcleritis or scleritis

Phenylephrine 2.5% and 10% test

Why Phenylephrine?

- alpha 1 adrenergic receptor agonist (sympathomimetic)

constriction of blood vessels

pupil dilation

muscle of mueller

Phenylephrine 2.5% and 10% test

Phenylephrine will black the SUPERFICIAL episcleral vessels and conjunctival vessles not the deep episcleral vessels

What causes Episcleritis?

2/3 are idiopathic

or systemic conditions

Basic Lab work for Episcleritis

Rheumatoid Factor

RA

Anti-CCP

RA

antinuclear antibody (ANA)

Non specific inflammation

C Reactive Protein

Non specific inflammation

Erythrocyte sediment r

Non specific inflammation

Serum uric acid

Gout

complete blood count with differential

wide range of conditions

VDRL (venereal disease research lab)

Syphilis

FTA-ABS (fluorescent treponemal antibody absorption)

Syphilis

QuantiFERON Gold

TB

PPD (tuberculin purified protein derivative)

TB

Chest X ray

Sarcoidosis and Tuberculosis

ACE

Sarcoidosis

HLA-B27

UCRAP inflammatory conditions

anti DsDNA

Lupus

UCRAP inflammatory conditions

Ulcerative Colitis

Crohn's Disease

*Reactive Arthritis*

Ankylosing Spondylitis

Psoriatic Arthritis

stomach and back problems

Treatment of mild episcleritis

refrigerated AT QID

Moderate to severe episcleritis

Topical NSAID: Ketorolac 0.4% QID for 10-14 days

Mild Topical Steroid: Loteprednol 0.5% QID for 10-14 days with taper

Oral NSAID:

Ibuprofen 200 mg to 600 mg tid to qid for 10-14 says

NSAID MOA

Inhibit COX

decrease inflammation

NSAID CI

Epi defects and thinning

NSAID ADR

sting upon installation

corneal melt with overuse

episcleritis follow up

1-2 weeks or sooner of worsens

Questions to ask pt presenting with episcleritis

1) Any history of autoimmune condisitons

2) any back pain or joint pain

3) any stomach probelms or IBS

4) fever/fatigue

5) Night sweats

6) has this happened before?

Scleritis

inflammation of the deep episcleral vessels

Scleritis epidemiology

- 2nd to 5th decade

- Women > Men

- Bilateral in 52% of pt

Patients with scleritis have a ______% chance of harboring systemic condition

25-50%

Uveitis develops in _____ of patients with scleritis

1/3rd

Pathophysiology of scleritis

exact pathogenesis of scleritis is unknown

disorder immune response leads to blood vessel adn tissue damage

Scleritis: Resident cells such as macrophages and fibroblasts produce

MMPs that break down the ECM that leads to inflammation and thinning of thes sclera

Scleritis: Signs and symptoms

- Severe and boring eye pain, often radiates to *forehead* (most defininf feature)

- pain upon eye movement

- gradual or acute

- tearing, photophobia, decrease in vision

- inflammation of episcleral, scleral, and conj vessels*

- areas of scleral thinning (blue hue)

Classificaitons of sclertitis

anterior

posterior

anterior scleritis tyes

diffuse

nodular

necrotizing (with and without inflammation)

Diffuse anterior scleritis

- most COMMON and LEAST severe

- diffuse inflammation

- salmon diffuse color or blue

superficial and deep vascular networks are inflamed

Diffuse anterior scleritis is most commonly assosicated with

Rheumatoid Arthritis

Nodular Anterior Scleritis

- nodules that are firm and IMMOBILE

- salmon or blue

- superficial and deep vascular networks are inflamed

Nodular Anterior Scleritis is most commonly associated with

Rheumatoid Atrhritis

Necrotizing Scleritis WITH inflammation

- most Severe form of anterior scleritis ( highest potential for vision loss

- EXTREME discomfort

- Superficial and deep vascular networks are inflamed

- Pronounced areas of thinning

_____% of Necrotizing Scleritis WITH inflammation assoca=iated with condition, most commonlt

50 - 81

Rheumatoid arthritis

Necrotizing Anterior Scleritis without inflammation

Scleromalacia Perforans

complete lack of symptoms

pronounced areas of thinning w our inflammation

MOST SEEN in elerfy women with RA!!!!!!!

Evaluation of Scleritis

Ocular eval with DFE

1) Phenylephrine 2.5% and 10% test

2) Check for presence of cells and flare

Phenylephrine 2.5% and 10% test: If redness stays

scleritis!

Posterior Scleritis Signs and symptoms

- S/s anterior scleritis

- choroidal folds and thickening

- circumscribed fundus mass

- exudative retinal detachment

- optic disc swelling

- Macular Edema

- proptosis

- onset of hyperopia

- Fluid build ip in epicsleral space T sign

B scans can dx Posterior sclerititis by showing

T sign

fluid accumulation in episcleral space

approx ___% of patients with scleritis have associaged systemic disease

most botabky with

50

necrotizing anterior scleritis

Systemic Conditions associated with Episcleritis and Scleritis

Rheumatoid Arthritis (RA)

systemic autoimmune condition characterized by inflammatory arthritis and extra articular involvement specifically in the synovial joints

Rheumatoid Arthritis (RA) pathophysiology

B cells and T cells will identify the host tissue as foreign and attack specifically in the synovial joints

Rheumatoid Arthritis (RA) signs and sypmtoms

joint stiffness and pain

swelling of joints

Rheumatoid Arthritis (RA) Lab work

RF

Anti CCP

ANA

Rheumatoid Arthritis (RA) co manangement

Rhuematology

Rheumatoid Arthritis (RA) Treatment

Systemic steroids

hydrxcychlroquine

Biologics (MAB against CD20, TNF Alpa ingibitor(

Ulcerative Colitis

idiopathic inflammatory condition of the large intestine that can result in the erosion of the colonic wall and associated bleeding

SEE NOTES

Crohns disease lab work

Anti-Saccharomyces Cerevisiae Antibody

SEE NOTES

Treatment of Sclertitis