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1. Patients with primary inflammation involving the iris and ciliary body are labeled as A. intermediate uveitis

B. pars planitis C. iritis D. iridocyclitis

2. Characteristics of non-granulomatous uveitis A. of insidious onset

B. presence of iris nodules

C. presence of large keratic precipitates

D. tend to have hypopyon in the anterior chamber

3. A patient presents with a history of a 4-week duration of eye redness. He claims that he has no history of any similar attack in the past. The patient probably has

A. Acute uveitis B. Recurrent uveitis C. Chronic uveitis

4. On ophthalmologic examination, a patient was found to have inflammatory changes in all parts of the uveal tract. The patient’s condition can thus be labeled as

A. Anterior uveitis

B. Peripheral or intermediate uveitis C. Posterior uveitis

D. Diffuse uveitis

5. Uveitis may be associated with bacterial infections. Common bacterial infections which may manifest in the eye as uveitis is

A. tuberculosis B. typhoid C. histoplasmosis D. sarcoidosis

PART IV. SCLERITIS

This section will deal with inflammatory conditions that involve the sclera and episcleral tissues.

A. EPISCLERITIS

This refers to a benign inflammatory disease characterized by edema and cellular infiltration of the episcleral tissue. The condition usually occurs in young adults, with females being more affected by males. The condition is usually bilateral in one third of cases and patients often complain of mild discomfort, specifically a slight ache, feeling of heat or irritation in the involved eye. Eye redness is commonly confined in the interpalpebral area and would blanch with instillation of 10% phenylephrine.

The condition can further be classified as follows:

A. simple episcleritis

• more common

• often self-limiting (2-19 days)

• may be recurrent

• episodes become less frequent after the first 3 to 4 years B. nodular episcleritis

• usually takes longer to resolve (4-6 weeks)

• underlying sclera is often normal

Systemic Associations are found in about one third of patients. This is however not correlated to the type,

onditions (spondyloarthropathies, inflammatory bowel disease)

s, giant cell

5. tic)

)

atients with episcleritis generally do not develop ocular complications, although uveitis, peripheral corneal

cleritis is a severe ocular inflammation which consists of edema and inflammatory cell infiltration of the

nlike episcleritis, patients affected with this condition are usually in their fourth to sixth decades of life.

Classification cleritis has been classified as follows (Watson and Hayreh)

e

th or without inflammation ( scleromalacia perforans) B. p

ach of these types will be discussed in detail in the subsequent section.

of insidious onset and may develop

Fig. 20. Nodular Episcleritis Fig. 19. Simple Episcleritis

laterality or chronicity of the disease. Systemic conditions associated with episcleritis include

1. connective tissue diseases ( rheumatoid arthritis, SLE, relapsing

2. polychondritis)

3. B27-associated c

4. vasculitic diseases ( polyarteritis nodosa, Behcet’s disease, Wegener’s granulomatosi arteritis, Cogan’s syndrome)

infections ( herpes, bacterial, fungal, parasi

6. miscellaneous conditions ( atopy, rosacea, gout P

inflammation and glaucoma may occur in a small percentage of cases. There have also been reports on a small number of these patients progressing to scleritis.

B. SCLERITIS

Ssclera. These changes are often immunologically mediated, or less commonly, the result of infection. Local trauma can also precipitate the inflammation. Without treatment it may be progressively destructive. It may also be the presenting symptom of an underlying lethal systemic condition or it may herald the onset of a

‘flare’ of an already diagnosed systemic disease thought to be in remission.

U

Females outnumber males to a small degree. The condition has been reported to occur bilaterally and is recurrent in about one third of cases. The main symptom of this condition is severe, penetrating eye pain which may radiate to the forehead, jaw and sinuses. Redness is gradual in onset and has a characteristic bluish-red tinge which may best be observed under natural light. Such redness fails to blanch with instillation of 10% phenylephrine or vasoconstrictors.

1. Diffuse anterior scleritis is the most common type of scleritis. It is

than necrotizing scleritis. The inflammatory process is localized to a nodule(s) which is immob

and tender to touch. As in the diffuse anterior type it is of insidious onset. In terms of severitile, firm y of the d

3.

arthritis, Wegener’s

granul n

. Necrotizing scleritis without inflammation or is painless condition characterized by the appearance of yellow-gray necrotic slough or

sequestru tion o The necrotic tissue eventually separates

a

. ong these conditions. It occurs twice as often in females

and affec ith anterior scleritis.

Frequently, patients are older than 50 years and have and increased risk of visual loss. Patients with this

Systemic conditions have been associated with approxi ate 50% of all scleritis cases. Table 5 shows a listing of these conditions.

isease, it is intermediate between that of the necrotizing type and posterior scleritis.

Necrotizing scleritis with inflammation is the most severe and destructive form. It is characterized by the presence of white avascular areas surrounded by swollen inflamed sclera (Fig. ). More than half of patients with this condition have associated systemic conditions such as rheumatoid

omatosis and relapsing polycho dritis. It is also the most frequently associated with ocular complications such as peripheral corneal thinning or stromal keratitis, uveitis, cataract, and glaucoma.

4

Fig. 22. Necrotizing Scleritis with Inflammation

Fig. 21. Anterior Nodular Scleritis

Scleromalacia perforans nodules that gradually develop a f the sclera.

m without surrounding inflamma

leaving the choroid b re, covered only the conjunctiva. Spontaneous perforation rarely occurs, although traumatic perforation can easily occur. This condition is almost always associated with rheumatoid arthritis.

5

Fig. 23. Necrotizing Scleritis without Inflammation (Scleromalacia perforans

Posterior scleritis has the lowest incidence am

ts both eyes in about one third of cases. It may also be associated w

condition complain of periocular pain, pain with eye movements and decreased vision. Other eye symptoms include conjunctival chemosis, proptosis, lid swelling, lid retraction and limitation of extraocular movements. Fundus examination may reveal disc swelling, choroidal folds, serous retinal detachment, uveal effusions and macular edema. Ultrasonography is the key to making a diagnosis of posterior scleritis.

Associated Diseases m

Table 5. Systemic Diseases Associated with Scleritis

• viral ( herpes zoster, herpes bacterial ( tuberculosis, syph

1. The main difference in the clinical presentation of scleritis from episcleritis is the presence of B. eye redness

2. sociated with the worst visual prognosis is leritis

erforans C. diffuse anterior scleritis

3. more frequently associated with scleritis is

. diabetes mellitus

4. calized eye redness of about five days duration. On examination, you note the , non-tender nodule. Your impression would be

. nodular episcleritis is

5. tion of the sclera which is associated with blurring of vision, proptosis and pain cleritis

D. necrotizing scleritis with inflammation The systemic condition that is