Anterior Sclera and Iris
EPISCLERITIS
Episcleritis is a benign, transient, recurrent, self-limited, and usually nonspecific condition that affects young adults. It rarely progresses to scleritis and should not be considered a milder form of scleritis. There are two forms: simple and nodular.
Etiology
• Idiopathic
• Collagen vascular diseases
• Rosacea
• Gout
• Herpes zoster, herpes simplex, syphilis
Symptoms
• Acute onset of redness, mild irritation, tearing, rarely pain
Signs
• Simple episcleritis
▪ Sectorial or diffuse hyperemia, primarily involving the middle episcleral plexus, with some secondary involvement of the overlying conjunctival vessels (Fig. 9-1A and B)
▪ The inflamed episcleral vessels have a straight, radial configuration.
▪ Topical phenylephrine 2.5% will cause blanching and enhance visualization of the normal deep vascular plexus over the sclera.
• Nodular episcleritis
▪ Somewhat tender, usually solitary, localized injected nodule that can be moved slightly over the sclera (Fig. 9-1C)
▪ A localized area of corneal thinning secondary to desiccation (delle) may develop adjacent to an episcleral nodule.
Differential Diagnosis
• Conjunctivitis: usually associated with papillary or follicular response in the tarsal conjunctiva. May have a mucoid or purulent discharge.
• Scleritis: Pain is deeper and more severe, sclera has a purple or bluish hue under natural light, injected scleral vessels have crisscrossing configuration, vessels are immobile over the globe, patients tend to be older.
• Inflamed pinguecula: located in the completely mobile conjunctiva
Diagnostic Evaluation
• Examination is made with the slit lamp and under natural or room light.
• Attempt to move the episcleral vessels over the sclera using a cotton-tipped stick under topical anesthesia.
• Apply phenylephrine 2.5% and observe for blanching of episcleral vessels after 15 minutes.
• Systemic workup if history is suggestive of collagen vascular disease or gout.
Treatment
• Artificial tears and cool compresses q.i.d.
• Consider a short course of a topical nonsteroidal anti-inflammatory drug (NSAID) (e.g., diclofenac q.i.d., ketorolac q.i.d., bromfenac q.d. or b.i.d., or nepafenac t.i.d.).
• Oral NSAID (e.g., ibuprofen 400 to 600 mg t.i.d. to q.i.d., indomethacin 12.5 to 25 mg q.d. to t.i.d., or flurbiprofen 100 mg b.i.d. to t.i.d.) for moderate-to-severe cases.
• Consider a short course of topical corticosteroids (e.g., fluorometholone 0.1% to 0.25%, loteprednol 0.2% to 0.5%) q.i.d. in recalcitrant cases. Rarely, stronger topical steroids (e.g., prednisolone 1% or difluprednate 0.05% q.i.d.) or oral corticosteroids are required.
Prognosis
• Good to very good. Episcleritis is often a recurrent condition.
 FIGURE 9-1. Episcleritis. A. Localized injection of the episcleral vessels is evident in this patient with sectorial episcleritis. B. Diffuse injection of the episcleral vessels is present in this eye. Episcleritis can be difficult to differentiate from scleritis in some patients. Episcleral vessels tend to blanch with topical phenylephrine 2.5%, whereas scleral vessels do not. |
 FIGURE 9-1. (continued) C. Nodular episcleritis is present inferotemporally in this left eye, which also has a central corneal ulcer many years after radial keratotomy. |
ANTERIOR SCLERITIS
Scleritis is a severe, potentially sight-threatening ocular disorder that has a totally different prognosis than episcleritis. It may be mild and benign or severe and destructive. Females are affected more often than males, and the condition is frequently bilateral. Most scleritis affects the anterior sclera. Anterior scleritis can be divided into the clinical forms described as follows.
Classification
• Non-necrotizing scleritis
▪ Diffuse: diffuse hyperemia and distortion of the pattern of the deep vascular plexus, associated with variable episcleral and conjunctival injection (Fig. 9-2A). This is the most benign form and is associated with the least severe systemic conditions.
▪ Nodular: tender, usually solitary, deep, localized injected nodule that cannot be moved over the sclera (Fig. 9-2B, eFig. 9-2B)
• Necrotizing scleritis
▪ With inflammation
▶ This is the most destructive form of scleritis. It is associated with ocular or systemic complications in 60% of patients, and 40% may have loss of vision. One-third of patients may die within a few years as a result of severe autoimmune disease, if they are inadequately treated.
▶ Gradual appearance of painful, localized, avascular patch overlying an area of scleral necrosis (Fig. 9-2C)
▶ Inflammation may be localized to the surrounding sclera or may become diffuse.
▶ The underlying uvea becomes progressively visible through the thinned and necrotic sclera (eFig. 9-2C).
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