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EPISCLERITIS/ SCLERITIS LT COL Ayyaz Hussain Awan TI(M) MBBS, DO, FCPS Assistant Prof EPISCLERA • Dense vascular connective tissue; which merges with superficial scleral stroma • Rich blood supply -> Ant. Ciliary Arteries, Long & short post ciliary arteries. SCLERA STROMA • Dense fibrous tissue intermingled with elastic tissue • Irregularly arranged collagen fibers Opacity of sclera • Visco elastic structure • Biphasic response to deforming force brief lengthening (elastic response) slow stretching (viscid response) LAMINA FUSCA (Suprachoroid lamina) APPLIED ANATOMY Sclera is covered with three vascular layers • The conjunctiva vessels Most superficial • The superficial episcleral vessels within tenon capsule and have redial configuration • The deep vascular plexus adjacent to sclera Functions of sclera • Protection of intra ocular contents from trauma & mechanical displacement. • Preservation of shape of eye ball. • Maintenance of exact position of different parts of optical system • Rigid insertion for extra ocular muscles EPISCLERITIS AND SCLERITIS 1. Episcleritis • Simple • Nodular 2. Anterior scleritis (98%- 85% + 13%) • • • • Non-necrotizing diffuse Non-necrotizing nodular Necrotizing with inflammation Necrotizing without inflammation ( scleromalacia perforans ) 3. Posterior scleritis (2%) Applied anatomy of vascular coats Normal • Radial superficial episcleral vessels • Deep vascular plexus adjacent to sclera Episcleritis • Maximal congestion of episcleral vessels Scleritis • Maximal congestion of deep vascular plexus • Slight congestion of episcleral vessels Episcleritis • Common, benign, self-limiting but frequently recurrent. Young adults, unilateral mild discomfort,tenderness • Seldom associated with a systemic disorder Simple sectorial episcleritis Simple diffuse episcleritis Treatment • Topical steroids • Systemic flurbiprofen (100 mg tid) if unresponsive SCLERITIS “Granulomatons inflammation of sclera” characterized by oedema and cellular infiltration of the entire thickness of sclera. Ranges from mild self-limiting episode of inflammation to severe necrotizing process which may lead to sight threatening Complications like Uveitis Cataract Keratitis Retinal edema Optic neuropathy SCLERITIS – Causes and associations : In 50% of cases • Rheumatoid arthritis • Connective tissue disorders – – – – Wegner granulomatous Relapsing polychondritis Polyarteritis nodosa SLE SURGICALLY INDUCED INFECTIOUS SCLERITIS Pseudomonas aeruginosa, Strep. Pneumoniae, Stap. Aureus, Varicella zoster virus ANTERIOR NON-NECROTIZING SCLERITIS Similar to episclertitis, although discomfort is more severe Inflammation involves deep vascular plexus 2.5% Isonephrine ( Phenylephrine) test NODULAR SCLERITIS: – Mimics diffuse scleritis – Nodule can’t be moved over underlying tissue – 25% cases having visual impairment ANTERIOR NONNECROTIZING SCLERITIS TREATMENT: – Oral NSAIDS : flurbiprofen 100 mg t.i.d meloxicam 7.5 mg t.i.d – Oral prednisolone : 40-80 mg daily – Combined therapy – Subconjunctival steroid injections: (Only for nonnecrotizing type) • Triamcinolone acetonide (40mg/ml) ANTERIOR NECROTIZING SCLERTIS WITH INFLAMMATION Gradual Pain which becomes severe and persistent, radiates to temple, brow or jaw, frequently interferes with sleep. Occlusion of blood vessels and appearance of an avascular patch which may coalesce with other separate necrotic areas. Scleral necrosis that may be associated with overlying conjunctival ulceration & visibility of underlying uveal tissue. Associated anterior uveitis. Bilateral in 60% cases, asymmetrical. Mortality rate - 25% within 5 yrs. ANTERIOR NON-NECROTIZING SCLERITIS WITH INFLAMMATION COMPLICATIONS: – Staphyloma formation – Perforation sec. to severe scleral thinning – Anterior uveitis: • Long standing uveitis may result into – Sec. cataract – Glaucoma – Macular oedema Poor prognosis High incidence of visual impairment ANTERIOR NON-NECROTIZING SCLERITIS WITH INFLAMMATIN TREATMENT – Oral prednisolone : 60-120 mg daily for 23 days – Immunosuppresive agents: • Cyclophosphamide • Azathioprine • Cyclosporin Combined therapy: • I/V methyl prednisolone 500-1000 mg + cyclophosphamide 500mg ANTERIRO NECROTIZING SCLERITIS WITHOUT INFLAMMATION (SCLEROMALACIA PERFORANS) Typically affects women with long standing rheumatoid arthritis Necrotic patch followed by melting of sclera Underlying uvea becomes visible Asymptomatic No effective treatment Posterior scleritis • Pain, Decreased vision, Lid oedema and fullness. • 20% of all cases of scleritis ,30% of patients have systemic disease • Treatment similar to necrotizing scleritis with inflammation Proptosis and ophthalmoplegia Ring choroidal detachment Disc swelling Choroidal folds Exudative retinal detachment Subretinal exudation Imaging in posterior scleritis Ultrasound Axial CT a a b a - Thickening of posterior sclera b -Fluid in Tenon space (‘T’ sign) Posterior scleral thickening ALLERGIC CONJUNCTIVITIS 1. Allergic rhino-conjunctivitis • Seasonal • Perrenial 2. Vernal kerato-conjunctivitis 3. Atopic kerato-conjunctivitis ALLERGIC RHINOCONJUNCTIVITIS MOST COMMON FORM OF OCULAR AND NASAL ALLERGY HYPERSENSITIVITY REACTION TO A SPECIFIC AIRBORNE ALLERGEN – SEASONAL ALLERGY – PERENNIAL ALLERGY TRANSIENT ACUTE ATTACK OF REDNESS, WATERING AND ITCHING CONJUNCTIVA HAS MILKY OR PINKISH APPAEARANCE TREATMENT TOPICAL MAST CELL STABILIZER or ANTIHISTAMINE VERNAL KERATOCONJUNCTIVITIS COBBLESTONE PAPILLAE GIANT PAPILLAE RECURRENT, BILATERAL, OCULAR INFLAMMATION BOYS AND YOUNG ADULTS IN WARM, DRY CLIMATES AN ALLERGIC DISORDER WHERE IgE AND CELL MEDIATED IMMUNE MECHANISMS PLAY AN IMPORTANT ROLE Limbal vernal Mucoid nodule Trantas dots VERNAL KERATOCONJUNCTIVITIS Punctate epitheliopathy Plaque formation (shield ulcer) Epithelial macro-erosions Sub-epithelial scarring VERNAL KERATOCONJUNCTIVITIS PSEUDOGERONTOXON TREATMENT • STEROIDS • MAST CELL STABILIZERS • ANTIHISTAMINES • SUPRATARSAL STEROID INJECTION ATOPIC KERATOCONJUNCTIVITIS Recurrent, Bilateral, Ocular Inflammation, Warm Dry Climates Young Patients With Atopic Dermatitis Eyelids Are Red, Thickened, Macerated And Fissured An Allergic Disorder, IgE And Cell Mediated Immune Mechanism TREATMENT – Topical: • Preservative Free Lubricants • Steroids • Mast Cell Stabilizers – Supratarsal Steroid Inj. – Systemic • Antihistamines • Antibiotics ATOPIC KERATOCONJUNCTIVITIS Infiltration of tarsal conjunctiva causing featureless appearance Inferior forniceal papillae Mild symblepharon formation BLISTERING MUCOCUTANEOUS DISEASES CICATRICIAL PEMPHIGOID STEVENS-JOHNSON SYNDROME OCULAR CICATRICIAL PEMPHIGOID Idiopathic, Subepidermal / Subepithelial Blistering And Scarring Autoimmune Disease Subconjunctival bullae Ulceration and formation of pseudomembranes Subepithelial fibrosis SYMBLEPHARON ANKYLOBLEPHARON OCULAR CICATRICIAL PEMPHIGOID TOTAL CORNEAL KERATINIZATION SECONDARY BACTERIAL KERATITIS OCULAR CICATRICIAL PEMPHIGOID TREATMENT – TOPICAL • STEROIDS • TEAR SUBSTITUTES • ANTIBIOTICS – SUBCONJUNCTIVAL MITOMYCIN-C INJECTION – SILICONE CONTACT LENS – SYSTEMIC TREATMENT (REQUIRED IN MAJORITY OF CASES) • STEROIDS • DAPSONE STEVENS-JOHNSON SYNDROME ACUTE, SEVERE, MUCOCUTANEOUS BLISTERING DISEASE PRESENTATION – FEVER, MALAISE, SORE THROAT, COUGH – CRUSTY EYELIDS – CONJUNTIVITIS WITH PATCHY CONJUNCTIVAL INFARCTION – NO FURTHER SCARRING OCCURS FOLLOWING THE ACUTE PHASE STEVENS-JOHNSON SYNDROME RESIDUAL FOCAL ACUTE CONJUNCTIVITIS CONJUNCTIVAL FIBROSIS COMPLICATIONS Symblepharon, Epiphora, Dry eyes, Keratopathy TREATMENT Systemic & topical steroids Acyclovir if herpes simplex is suspected