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43 Cards in this Set
- Front
- Back
inner layer of sclera
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lamina fusca; blends with suprachoroidal and supraciliary lamellae of the uveal tract
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anterior episclera
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dense, vascular; between superficial scleral stroma and Tenon capsule
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most superficial vascular layer covering ant. sclera
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conjunctival vessels -> arteries tortuous, veins straight
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middle vascular layer covering ant. sclera
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vessels within Tenon capsule
-"superficial episclera" -vessels straight with radial config. -can be manually moved over sclera -most congested layer in episcleritis -topical phenylephrine will blanch (whiten) conjunctiva and Tenon vessels |
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deepest vascular layer covering ant. sclera
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deep vascular plexus
-covers superior part of sclera -"deep episclera" -most congested layer in scleritis -phenylephrine will not blanch (whiten) this layer |
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scleral stroma is largely {vascular/avascular}
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avascular
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episcleritis, general info
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-common, benign, self-limiting, frequently recurrent
-typically affects young adults -may be associated with systemic disease -NEVER progresses to a scleritis -may be simple (most common) or nodular |
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episcleritis S/S
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unilateral redness; mild discomfort, tenderness, watering
simple -> sectoral redness (diffuse less common) nodular -> sectored redness; localized, raised, congested nodule involving Tenon capsule (ant. sclera not raised) |
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diffuse redness in episcleritis often confused for ______________, DDx is...
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conjunctivitis; palpebral surface won't be red in episcleritis (no palpebral sclera) but will be in conjunctivitis
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_______ episcleritis typically recurrent, results in...
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nodular; superficial scleral lamellae become more parallel, making sclera appear translucent (this is not scleral thinning)
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_______ episcleritis resolves spontaneously within _________; _______ episcleritis takes longer to resolve
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simple; 1-2 weeks; nodular
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episcleritis Tx
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mild cases -> simple lubricants or vasoconstrictors
more symptomatic or recurrent cases -> topical steroids prolonged inflammation or severe recurrent cases -> oral NSAIDS |
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scleritis, general info
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-red and VERY painful
-edema and cellular infiltration of entire thickness of the sclera -MUCH less common than episcleritis -varies from trivial self-limiting to necrotizing |
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scleritis etiologies
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-systemic associations
-surgically induced -infectious |
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scleritis, systemic associations
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-50% of patients
-rheumatoid arthritis most common by far |
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scleritis, surgically induced
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-etiology unknown
-typically within 6mo post-op -more common in females -focal area of intense inflammation and necrosis adjacent to Sx site |
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scleritis, infectious
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-most commonly from corneal ulcer infection
-may be associated with trauma -may follow excision of pterygium -most common organisms: Pseudomonas, Strep., Staph., Varicella Zoster |
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scleritis, anatomical classification
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-anterior scleritis (98%)
> non-necrotizing (85%): diffuse or nodular > necrotizing (13%): w/ or w/out inflam. -posterior scleritis (2%) - post. eye, difficult to Dx |
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diffuse ant. non-necrotizing scleritis signs
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inflammation (sectoral or entire ant. sclera), distortion of normal radial pattern, benign (doesn't progress to nodular)
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nodular ant. non-necrotizing scleritis signs
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may resemble nodular episcleritis, scleral nodule can't be moved, intermediate severity (visual impairment ~25%)
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ant. non-necrotizing scleritis Tx
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-oral NSAIDs
-oral prednisone in patients resistant to or intolerant of NSAIDs -combined therapy -> NSAID + lower dose of steroid, used when either alone ineffective -subconjunctival steroid injection -> systemic therapy used only for non-necrotizing disease |
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ant. necrotizing scleritis with inflammation
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-most severe form of scleritis
-bilateral 60% but often not simultaneous -usually associated systemic vascular disease -mortality rate of 25% within 5 yrs -visual prognosis poor |
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ant. necrotizing scleritis with inflammation symptoms
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-pain -> radiates to temple, brow, or jaw and responds poorly to analgesia
-localized redness |
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ant. necrotizing scleritis with inflammation signs (in chronological order)
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-congestion of deep vascular plexus
-vascular distortion and occlusion with resultant avascular patches -scleral necrosis which gradually spreads -scleral thinning upon resolution -> bluish tinge due to uveal visibility |
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ant. necrotizing scleritis with inflammation complications
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-Staphyloma (bulge/protrusion of uveal tissue) formation and occasional perforation, esp. if IOP elevated
-ant. uveitis -> extension of inflam.; may develop 2° cataract, glaucoma, and macular edema; high incidence of visual impairment |
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ant. necrotizing scleritis with inflammation Tx
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-oral prednisolone -> reduces severity of pain
-immunosuppressive agents -> necessary in steroid resistant cases -combine therapy -> intravenous steroids and immunosuppressive agent; reserved for patients who fail to resolve with oral therapy or have established scleral necrosis |
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ant. necrotizing scleritis without inflammation
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-a.k.a. scleromalacia perforans
-more common in women with long-standing rheumatoid arthritis -typically bilateral -Tx ineffective |
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scleromalacia perforans
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ant. necrotizing scleritis without inflammation
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ant. necrotizing scleritis without inflammation signs (in chronological order)
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-asymptomatic yellow necrotic scleral patches in uninflamed sclera
-enlargement, spread and coalescence -progressive exposure of underlying uvea (scleral thinning) -Staphyloma formation (bulge/protrusion of uveal tissue) |
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staphyloma
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bulge due to protrusion of sclera or cornea, usually lined with uveal tissue
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post. scleritis
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-uncommon and often mis-Dx
-affects women twice as much as men -patients over 50 at increased risk -2/3 cases unilateral -no correlation with systemic disease -1/3 cases - permanent visual impairment -presentation variable, depends on affected area |
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post. scleritis S/S
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-pain and visual impairment most common symptoms
-blepharedema, proptosis, ophthalmoplegia, associated ant. scleritis 1/3 of cases -disc swelling, macular edema, choroidal folds, exudative retinal detachment, ring choroidal detachments, subretinal lipid exudation |
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post. scleritis testing
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-ultrasonography -> thickening of post. sclera and fluid in Tenon space; "T" sign
-CT scan -> post. scleral thickening |
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post. scleritis DDx
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-optic neuritis
-rhegmatogenous retinal detachment -choroidal tumor -orbital inflammatory disease or mass -uveal effusion syndrome -Harada disease -intraocular lymphoma |
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post. scleritis Tx
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-older adults -> oral predisolone, immunosuppressive agents, combined therapy
-young patients -> respond to NSAIDs |
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scleral discoloration, focal
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-senile scleral translucency
-alkaptonuria -haemochromatosis -systemic minocycline/tetracycline -metallic F.B. -> rust staining |
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senile scleral translucency
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-normal with old age
-oval, dark-grayish areas -white halo surrounding area |
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alkaptonuria
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-brown-black discoloration at the insertions of horizontal recti and pigmentation of the pinnae (auricle, outer ear)
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haemochromatosis
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-excess iron deposited over time
-rusty-brown discoloration |
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systemic minocycline
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-causes blue-gray paralimbal discoloration in interpalpebral area
-photosensitizing properties |
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scleral discoloration, diffuse
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-yellow -> jaundice
-blue -> scleral thinning |
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causes of scleral thinning
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-ant. necrotizing scleritis with and without inflammation
-Osteogenesis imperfecta -Ehlers-Danlos syndrome -Pseudoxanthoma elasticum -Turner syndrome |
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scleral discoloration, miscellaneous
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-Phtisis Bulbi -> shrunken eye and calcified sclera due to chronic, long-term, untreatable disease or improperly treated trauma
-Melanosis Oculi -> flat, dark pigment on sclera in dark-skinned people; not a concern -Axenfeld's Loop -> normal situation in which nerve comes up then loops back, causing a small dark spot; often superior sclera |