Episcleritis
Simple episcleritis
Diagnosis
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Presentation: acute onset of redness and mild discomfort.
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Signs: hyperaemia may be sectoral (typically interpalpebral; Fig. 8.1 ) or diffuse.
Fig 8.1
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Course: spontaneous improvement occurs within several days, but recurrences may occur.
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Treatment: not required if mild; otherwise lubricants or a weak steroid four times daily for 1–2 weeks.
Nodular episcleritis
Diagnosis
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Presentation: less acute onset than simple episcleritis with redness and discomfort worsening over 2–3 days.
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Signs: (a) one or more tender interpalpebral nodules ( Fig. 8.2 ), and (b) absence of deeper scleral thickening; after several attacks, the vessels surrounding the inflamed area may become permanently dilated.
Fig 8.2
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Course: more prolonged than simple episcleritis.
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Treatment: similar to that of simple episcleritis.
Immune-mediated scleritis
Anterior non-necrotizing scleritis
Definition: scleritis involves oedema and cellular infiltration of the entire thickness of the sclera; it is much less common than episcleritis and ranges from a trivial and self-limiting to a necrotizing sight-threatening condition.
Diagnosis
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Presentation: in 5th decade with redness, discomfort, and aching.
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Diffuse disease: redness; generalized ( Fig. 8.3 ) or localized to one quadrant.
Fig 8.3
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Nodular disease: (a) single or multiple scleral nodules, of a deeper blue-red colour than episcleral nodules, and (b) vascular congestion and dilatation with oedema and displacement of the entire beam of the slit lamp ( Fig. 8.4 ).
Fig 8.4
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Course: as inflammation settles, the affected area often takes on a slight grey/blue appearance due to increased translucency ( Fig. 8.5 ); episodes recur over several years, with the frequency decreasing after approximately 18 months.
Fig 8.5
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Prognosis: usually good, although more than 10% of patients with nodular scleritis develop necrotizing disease if early treatment is not instituted.
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Anterior necrotizing scleritis with inflammation
Definition: aggressive form of scleritis, bilateral in 60%, which may result in severe visual morbidity unless appropriately treated.
Diagnosis
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Presentation: later than in non-necrotizing scleritis with the gradual onset of pain that becomes severe and radiating, often interfering with sleep and responding poorly to analgesia.
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Vaso-occlusive type: often associated with rheumatoid arthritis; (a) starts as isolated patches of scleral oedema with overlying nonperfused episclera and conjunctiva, and (b) may progress to scleral necrosis ( Fig. 8.6 ).
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