Onemocnění bělimy Synek S. KOO Anatomické poznámky •Episkléra •Skléra •Lamina fusca Zánětlivá onemocnění skléry •Episkleritis, ložiskové nebo difúzní, často bolestivé na tlak •Skleritis, překrvení – hluboká injekce, bolestivé, u zadní skleritidy pak protruze bulbu, bolesti při pohybech oka •Sklerokeratitidy- zánět přechází na rohovku- herpes viry, tbc, revmatismus, lepra, onchocerkóza • EPISCLERITIS AND SCLERITIS 1. Episcleritis • Simple • Nodular 2. Anterior scleritis • Non-necrotizing diffuse • Non-necrotizing nodular • Necrotizing with inflammation • Necrotizing without inflammation ( scleromalacia perforans ) 3. Posterior scleritis Etiologie •Herpes zoster •Choroby vaziva: rheumatiodní arthritida, lupus erythematodes, polyarteritis nodosa, Wegner` s granulomatosis •Sarcoidosis, tuberculosis Léčba •Nesteroidní antiflogistika- indomethacin 100 mg for 4 days, celkkově prednisolone 60 / 80 mg, imunosupresiva •Specifická léčba antituberculostatika Applied anatomy of vascular coats Scleritis • Maximal congestion of deep vascular plexus • Slight congestion of episcleral vessels • Maximal congestion of episcleral vessels Episcleritis Normal • Radial superficial episcleral vessels • Deep vascular plexus adjacent to sclera C:\My Documents\a1.JPG C:\My Documents\a3.JPG C:\My Documents\a2.JPG Simple episcleritis • Common, benign, self-limiting but frequently recurrent • Typically affects young adults Treatment • Seldom associated with a systemic disorder Simple sectorial episcleritis Simple diffuse episcleritis • Topical steroids • Systemic flurbiprofen ( 00 mg tid if unresponsive C:\My Documents\Epi3.JPG C:\My Documents\Epi4.JPG Nodular episcleritis • Less common than simple episcleritis • May take longer to resolve • Treatment - similar to simple episcleritis Localized nodule which can be moved over sclera Deep scleral part of slit-beam not displaced C:\My Documents\Epi5.JPG C:\My Documents\Epi6.JPG Causes and Systemic Associations of Scleritis 1. Rheumatoid arthritis • Wegener granulomatosis • Polyteritis nodosa • Systemic lupus erythematosus 2. Connective tissue disorders 3. Miscellaneous • Relapsing polychondritis • Herpes zoster ophthalmicus • Surgically induced C:\My Documents\Epi8.JPG Diffuse anterior non-necrotizing scleritis • Widespread scleral and episcleral injection • Relatively benign - does not progress to necrosis • Oral steroids if unresponsive Treatment • Oral NSAIDs Nodular anterior non-necrotizing scleritis Scleral nodule cannot be moved over underlying tissue More serious than diffuse scleritis On cursory examination resembles nodular episcleritis Treatment - similar to diffuse non-necrotizing scleritis C:\My Documents\Epi9.JPG C:\My Documents\Epi10.JPG Anterior necrotizing scleritis with inflammation Progression • Painful and most severe type • Complications - uveitis, keratitis, cataract and glaucoma Treatment • Oral steroids • Immunosuppressive agents (cyclophosphamide, azathioprine, cyclosporin) • Combined intravenous steroids and cyclophosphamide if unresponsive C:\My Documents\epi12.JPG Scleral necrosis and visibility of uvea C:\My Documents\Epi13.JPG Spread and coalescence of necrosis C:\My Documents\epi11.JPG Avascular patches • Asymptomatic and untreatable • Associated with rheumatoid arthritis Progressive scleral thinning with exposure of underlying uvea Anterior necrotizing scleritis with inflammation (scleromalacia perforans) C:\My Documents\Epi14.JPG C:\My Documents\epi15.JPG C:\My Documents\Epi18.JPG C:\My Documents\Epi17.JPG C:\My Documents\Epi21.JPG C:\My Documents\Epi20.JPG Posterior scleritis Signs • About 20% of all cases of scleritis • About 30% of patients have systemic disease • Treatment similar to necrotizing scleritis with inflammation C:\My Documents\epi16.JPG Choroidal folds Subretinal exudation Proptosis and ophthalmoplegia Disc swelling Exudative retinal detachment C:\My Documents\Epi.JPG Ring choroidal detachment Imaging in posterior scleritis Ultrasound a - Thickening of posterior sclera b -Fluid in Tenon space (‘T’ sign) C:\My Documents\Epi22.JPG C:\My Documents\Epi23.JPG Axial CT Posterior scleral thickening a b a episkleritida • Skleritida Stafylom Skleritis Stafylom Episkleritida