Episcleritis & scleritis

Question 1

How to differentiate episcleritis/ scleritis/ conjunctivitis

Answer 1

2.5% phenylephrine
- conjunctival vessels blanched
Deep inflammation (epi/scleritis) - drops do nothing

Question 2

Features of simple episcleritis (80%)

Answer 2

• mild-mod, non-granulomatous, red eye, acute, tender, mild photophobia, watering, normal vision, recurrences
• deep diffuse hyperaemia
• pinkish hue, no blanching on vasoconstrictor, no movement, oedema (thickening), no AC reactions

Question 3

Features of nodular episcleritis

Answer 3

• Stronger association with other disease: RA, prev HZO, Gout
• Hyperaemia, raised mobile nodule, mild AC reaction possible

Question 4

Episcleritis mx

Answer 4

• Mild case: self limiting (hot compress q3h-4h, lubricants/ vasoconstrictors, mild topical pulsed steroid if necessary - FML/ Flarex qid, oral NSAID)
• Severe: as above + more potent steroid (prednisolone acetate/ Pred forte 1% qid, oral NSAID, medical workup)

Question 5

What are some scleritis associated conditions?

Answer 5

• Systemic: RA (50%), polychondritis
• Anterior segment sx: scleral buckling, vitrectomy, trabeculectomy
• Infections: viral (HZO), bacterial, fungal
• Drugs: biphosphonates

Question 6

Features of anterior non-necrotising scleritis

Answer 6

• Diffuse = widespread inflammation, benign, refer, mx similar to severe episcleritis (potent steroids)
• Nodular = non-mobile nodule, tender to touch, severe symptoms, refer, potent steroid (prednisolone 1% q2h 4 days then qid), oral NSAID or steroid, subconj injection (triamcinolone)

Question 7

Anterior necrotising w inflammation scleritis

Answer 7

• Severe, may be bilateral, systemic associations common
• gradual onset pain/redness, severe pain, temple brow jaw
• congested deep vascular plexus
• vascular distortion and occlusion
• scleral necrosis
• Limbal –> risk of corneal involvement = sclerokeratitis
• Complications: staphyloma, anterior uveitis
• MX: refer, oral NSAID, oral prednisolone, immuno-suppressive agent

Question 8

Features of anterior necrotising without inflammation scleritis

Answer 8

• Bilateral
• associated with long-standing RA
• Asymptomatic yellow plaques (no inflamm), scleral thinning, enlargement of plaque, staphyloma uncommon, no effective tx
• no steroids

Question 9

Features of posterior scleritis

Answer 9

• uncommon, systemic disease, F>M
• pain (worse on eye movement), visual loss - push on retina or ON
• external signs: lid oedema, proptosis, ophthalmoplegia, anterior slceritis
• fundus: disc oedema, MO, choroidal folds, exudative RD, subretinal lipid
  Tx: similar to anterior necrotising scleritis