episclera,

limbal arcades,

tenon's,

anterior conjunctiva

Deep Episclera,

Iris Arteriorles (long posterior ciliary arteries)

Nodule moveable, redness in section of 1 or both eyes,

No Scleral or musculature involvement

Mild pain (generally not painful!)

Acute onset of redness,

no discharge,

h/o recurrent episodes

No Treatment, self-limiting,

Mild: iced articial tears(qid), topical decongestants,

cold compresses

Moderate to Severe:

Mild Topical steroid (loteprednoal Alrex x2%, lotemax 5% or fluorometholone taper),

Oral Asa or NSAID's (ibuprofen or naproxen)

Drop of phenylephrine 2.3% in affected eye, wait 15mins episcleral vessels should blanch.

If hx of underlying etiology:

Lab Tests: Antinuclear antibody, rhematoid factor, erthrocte sedimentation rate)

serum uric acid level

FTA-ABS

• ANA (antinuclear antibody)

• Rheumatoid Factor

• ESR (Erythrocyte Sedimentation Rate)

• Serum Uric Acid level

• FTA-ABS (test for antibodies for syphillis)

• Generalized, moderate, episcleral swelling and injection 

Greyish Infiltrates,

• Resolves ~ 1-3 weeks (first week ok 50% of time)

is 78-83% of episcleritis cases

• Moveable nodule of localized edema within the area of injection (1 or more)

• Resolves ~8 weeks

ocurrs in 17-22% of episcleritis cases

Episcleritis Follow up:

• if on Steroids: check weekly, IOP

• if on Artificial Tears or vasoconstrictor: check in 2-3 weeks

AVASCULAR, low metabolism: choroid and episclera,

fully hydrated,

firm flexible and protective, collagen and elastic bndles,

continous with corneal stroma

• Inflammaed scleral, episcleral and conjuntival vessels.
• Injection: red sclera and conj

Sclera: bluish hue in tatural light grossly

Vision maintained unless uveitis occurs.

Wide spread inflammation of ant. sclera, most common and most benign with NO progression

1 or more IMMOVABLE, erythematous, tender, inflamed nodules/edema on anterior sclera

20% of cases progress to necrotizing scleritis

resolve ~8 weeks

Granulomatous inflammation of deep episcleral plexus.

May lead to blindness and eye loss

Choroidal Vasculature to intraocular complications

• uveitis
• retinitis and retinal detachment
• GLC
• Cataract
• Cornea: peripheral keratitis, lumbal gutterring

More prevalent in 40-60yo females

Emergency! Sclelar thinning, blue tinge,

Gradual, very painful,

red eye,

 sclero keratitis(if associated with corneal inflammation)

• Freuently accompanies seriosu systemic collagen vascular disorders (RA)
• Exreme pain
• Maked damage to sclera--> transparent, choroidal pigment visible in daylight
• necrosis/avascular patch
• conjuntiva may perforate

in 98% of scleritis px,

sclerosing keratitis,

cataract,

hyphema

retina: staphyloma & Ectasia,

Secondary glaucoma

Most Severe form
Vision threatening complications,

permanents visual loss.

Staphyloma  (complication of anterior necrotizing scleritis with inflammation)

Thinnig of Sclera, Bulging of Uvea (iris &CB) INTO an area of thin, stretched uvea

• congenital/acquired
• Scleritis
• myopia
• rd,
• ct disease
• BIO and a & b scan

NO pain, due to rheumatoid nodule in sclera.

Visible avascular patch,

tissue thins, necrotizes and sloughs with steady progression.

Perforation rare, unless high IOP,

older females

Oral Prednisone

Immunosuppressive agents

Abundant lubrication

Severe: eye surgery, scleral patch grafting

Restricted EOM's

• proptosis, pain, tenderness

• Decreased vision (permanent)

Differential: Retrobulbar optic neuritits (RD), tumor, orbital disease

Unrelated to systemic disease

(2% of type of scleritis)

• Disc Swelling

• macular Edema

retinal Hemorrhage

Retinal Detachment

Vitritis

Choroidal Folds or detachment

Intraretinal white deposits

Aspirin

NSAIDs

Steroids

Immunosuppressive Tx

remove foreign body

glasses/eyshield (if thinning and perforation risk)

Subconjunctival steroids contraindicated in necrotizing scleritis

• Complete blood count

• ESR

• uric Acid

FTA-ABS

Rheumatoid Factor

ANA

Fasting blood sugar

PPD

Radiograph of sacroilliac joints

Deep Pain radiating from ipsi side of face

Conjunctival manipulation

OTC decongestants

give 10% phenylephrine and conjuntival vessels WILL BLANCH.

Vessels of deep scleral plexus will not blanch.

• Sclerosing Keratitis

• Cataract

• Hyphema

• Retina: Staphyloma, Ectasia

• Secondary glaucoma

Congenital Anomalies:

1. Pigment Cuffs

• Short anterior ciliary arteries

• Bluish cuff

associated with anterior cilary nerves (axonfeld's loop)

Congenital Anomalies:

2. Blue Sclera

tissue color due to scleral thinning and exposed uvea

Normal in infants

Congenital Anomalies:

3. Osteogenesis imperfacta

Permanent blue sclera

Involves skeleton, ear, joints, teeth, skin, & eyes

Inherited

3 signs: blue sclera, deafness and bone fractures

Congenital Anomalies:

4) Melanosis Oculi

Hyperpigmentation of conj, episclera, sclera, uvea and choroid.

Bilateral.

Congenital Anomalies:

5. Nevus of Ota or "oculodermal meloncytosis"

• Pigmentation of the periorbital skin, blue/purple/mottled
• Lid, lid margin, or entire face--> distributed along CN V₁ AND V₂

• Malignant degeneration

Congenital Anomalies:

6. Senile Hyaline Plaque

• Localized non-inflammatory thinning that is translucent, grey, flat, oval patch anterior to insertion of MR &LR

>50 yo

• Symptomless, benign &common

Reassurance&monitor

Yellow pigmentation of the sclera or skin due to high concentration of bilirubin in the blood

(medical exam)

Varying Pain

Sight may not be detectable

Associated with conjuntivitis, keratitis, uvietis, intraocular heme, decreased IOP, hemosiderosis

Work-up Gonio, DFE, B-scan, CT scan, No MRI'S

Tx: Immediate hospitalizations

Fox Shield

• Inflammatory enlargement of the lacrimal gland

Acute

Chronic

Infectious or systemic etiology

Less Severe:

• NO PAIN
• Enlarged lacrimal gland but mobile
• Minimal ocular signs
• Mild ptosis noted secondary to enlargement of the gland
• Mild-to-severe dry eyes

palpate, palpebral lobe firm and tender

Signs/sx

• Unilateral
• Severe pain
• Redness & swelling over outer third of upper eyelid
• Rapid Onset (hrs to days, they come in the next day)

 Acute Dacryoadenitis

signs

chemosis

conjunctival injxn

Mucopurulent discharge

Erythema of eyelids

Lymphadenopathy

Swelling of the lateral third of the upper lid (S-shaped lid)

Proptosis (prominent in one eye more)
Ocular Motility restriction

Globe displacement

Smear and culture, if purulent

Blood cultures to rule out N. gonorrhoeae

Immunoglobin titers to specific virus

Usually seen with chronic system conditions like

1. Sarcoidosis
2. Sjogren syndrome
3. Graves Disease
4. Seek advice from the px internist
5. Lacrimal gland biopsy may be helpful

Rule out infectious causes (rare): syphillis, leprosy, tuberculosis, and trachoma (bacterial infxn with Chlamydia trachomatis)

Acute Dacryoadenitis

Imaging Studies

CT scan of the orbits HELPFUL

No compressive changes in the contiguous bone or globe are noted

Viral: Self-limiting, cool compresses to area of swelling--> analgesic prn

follow-up: daily

Bacterial or infectious:

Mild/moderate:

Reflex until culture results are obtained

Aduts orally 4x/day =PO QID

Children orally 4x/day PO QID

Moderate/severe: hospitalized

Hospitalize if moderate to severe.

InflammatoryL investigate for systemic etiology and treat accordingly

Treat the underlying systemic condition--> consieder the lacrimal gland biopsy.

Consultations: if sarcoidosis, tuberculosis, Sjogren syndrome, or Graves disease as the etiology. consult.

Sx: discomfort, visual disturbance, tear film instability w/ potential damage to ocular surface.

Accompanied by increased osmolarity of tear film and inflammation of the ocular surface

• Dryness results from reduced lacrimal tear secreation and volume
• Causes tear hyperosmolarity--> epithelial cell hyperosmolarity --> inflammatory events