Episclera and Sclera Collagen (1)

8/13/2019 Episclera and Sclera Collagen (1)

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EPISCLERA and SCLERA

EPISCLERA SCLERA

characteristics

- above sclera

- Loose vascular complex between conj and sclerawithin Tenons capsule

- Superficial and deep plexus derived from anterior and posterior ciliary

arteries

Superficial = radial arranement! larer in

caliber than conjunct vessels! "oins with

conjun vessels at limbus #eep plexus = $%T scleral vessels! closely

applied to sclera! irreular nonradial

confiuration!-

- collaen with small amt of proteolycans arraned

in criss cross pattern- thic&ness varies from '()-'(*+ mm near optic nerve

and thins anteriorly- thinnest immediately behind insertion of ,%S

- ./.S01L.2

- .nteriorly continuous with cornea3 division is atlimbus

- 4ave endothelial pumps- 5osteriorly continous with dura sheath coverin

optic nerve

Functions - .cts as synovial membrane for smooth movementof eye

- Supplies nutrition to ./.S01L.2 sclera

- protective coverin- bloc&s extraneous liht from enterin lobe

- site of insertion of ,% 6resists lobal chaneswith eye movement7

-

Things to remember - 0.$ 6do and will7 have an episcleritis 89T4%1T

a scleritis- 0.$$%T have an scleritis 89T4%1T an

episcleritis- ,piscleritis is very common red eye seen in

clinical practice

- ./.S01L.2

- 0an be ruptured with direct trauma- .ny inflammation is due to autoimmune d: and d:

processes of collaen fibers- 8ith ae3 increased thic&ness and riidity and

increased fat deposition 6appears yellow7- "aundice can also cause yellowin of sclera

-

Inflammation

,pidemioloy

Episcleritis- ;enin3 self-limitin inflammation of episclera

6superficial plexus7! usually resolves in


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0auses

5athophysioloy

- Stress3 hormones 6why f?m7 simple episcleritis

intermittent boults of moderate to severe

inflammation recur at '-* month intervals episode lasts B-') days

most resolve after ?

- C-Dthdecades with pea& incidence in + thdecade

6reported in patients from ''-@B yrs of ae7- ;ilateral

- 4ih association with systemic d:

- 0an be presentin manifestation of collaenvascular disorder and preceded additional

symptoms by ' to several months

- ? +)A are associated with underlyin systemic d:- CA annual rate of developin systemic d: in

patients w( initially dx idiopathic scleritis

- 529.2E inflammation of sclera

- .utoimmune in nature

- ? +)A demonstrate systemic d: associations


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Types 1. Simple or iffuse !"#$ of cases%- ,ntire anterior sement 6*)A7

- Section 6B)A7- 0ornea not involved

- $% dischare&. 'odule !$%

- 0entral pale nodule accumulation of inflammatory cells

6sectoral episcleritis wF build up of non-

ranulomatous material results in centralpale nodule7

mobile 6move with touch7

does not undero necrosis 6if it does3 thin&

scleritis7

- 2esolution is usually slower than simple episcleritis- Tender but not painful

1. Anterior iffuse

- 5resentation can be sectoral or diffuse

- 'F* have underlyin systemic conditions&. Anterior 'odular

- 5resents much li&e nodular episcleritis- $odule immobile and /,2E tender G painful to

touch

(. 'ecroti)ing Anterior- 0an be 89T4 or 89T4%1T inflammation

- Tissue meltin away- Scleromalacia perforans 6scleral thinnin7 w(o

inflammation! indicative of lon-standin severe2.

- ajority of underlyin cause

- 0haracteri:ed by avasculararea of scleral necrosisand profound inflammation of surroundin sclera

- /enulitis leads to vaso-occlusion and later to vaso-

obliteration*. Posterior

- 9nvolves sclera enclosed by orbital tissue

- 2are3 accounts for '-+A of scleritis cases- 1sually unilateral! >? H! all aes

- $o underlyin cause found

- Non specificpresentation! difficult or oftendelayed dx

- 5ain 6persistant3 worsen with eye movements73

reduced acuity3 diplopia3 ,% restrictions

- 5resentin features may include choroidal mass3 wFor wFo effusion3 choroidal folds3 cystoid macularedema or exudative retinal detachment

- Tenderness3 proptosis3 vision loss and restricted

motility- Testin

Iuantitative .-Scan( Ultrasonographyisusually dianostic

#emonstratin thic&enin of affected sclera

;-scans can be used to follow tx sucess

- 2esponds best to oral corticosteroid3 prednisone


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+hat brings patient

in,

- relatively asymptomatic acute onset of redness in

one or both eyes

- mild discomfort 6>; sensation7! not painful- waterin but $% dischare

- radual3 insidious onset of pain and redness

- bilateral or unilateral

- associated with photophobia3 tearin3 decreasedacuity

-o is / made, - 0linical presentation

- 4J systemic d:H! onset 6sudden and unilateral7!pain level 6minimal discomfort or irritation7

- 5rove its $%T episcleritis

- 5.9$ 6severe3 borin pain that radiates( #efinitepain with palpation7

- 5hotophobia- #ecreased vision

0I E2amination - 1nilateral 6most of the time7 or bilateral 6if it isbilateral3 thin& systemic d:7

- 2edness 6usually wede or sector! can be diffuse7- obile nodule or not

- #efinitely no dischare KKKK

- /essels will blanch with instillation of larex

- #examethasone- Lotemax

- .t least I9# 6 up to M


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- 5atient education about recurrence

- >or severe cases that do not respond well to tx

ormore than three recurrences refer for med eval

handled by an Oit is ophthalmoloist specialist

orFand rheumatroloist

ifferential /3

complications

##J- Scleritis

- 0onjunctival abrasion or >;- Superior limbic &eratoconjunctivitis of Theodore

- 5hlyctenular &eratoconjunctivitis- 5inueculitis- .cute anle closure laucoma

- 9ntraocular tumors with overlyin lobe injection-

0omplications- 5eripheral ulcerative &eratitis

- 5erforation- Secondary laucoma

- Scleral meltin- 5erforation- ,xudative retinal detachment

Prognosis - ,xcellentN

- $o seMuelae

- 2arely any underlyin d: process ever found 6otherthan alleriesP7

- $ot reat3 not even ood

- uarded at best

- 'CA lose sinificant /. wFin ' yr of dx- *)A lose sinificant /. in * yrs

- Sinif percentae of patients w( concurrent scleritis

and collaen vascular d: die wFin + yrs

Sclero7eratitis

- 042%$90 process mar&ed by area of %5.09>9,# and/.S01L.29Q,# cornea3 which proresses toward visual

axis- .ssociated with peripheral and paracentral 1L0,2.T9/,

&eratitis3 mar&ed by juxtalimbal or central corneal thinnin

0lue Sclera

- bluish discoloration secondary to thinned sclera

- $eonates and .. children normal variation- .cMuired Oassociation with arfans syndrome and other

systemic d:

- /ery uncommon

Scleral -8aline pla9ues

- small round translucent to rayish areas

- calcium deposition in area of scleral thinnin associated wF reorani:ation of scleral fibers due to ae- ;enin $o TJ

Sclera Ectasia

- stretchin of sclera

- conenital abnormality around nerve head or macula- may follow inflammation or trauma

- may result from proloned 9%5 elevation in infancy

- may occur with hih 6proressive7 myopia

Staph8loma

- wea&ened sclera allows for bulin of uvea- anterior-eMuatorial posterior

- causes decreased /.

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Episclera and Sclera Collagen (1)