Scleral edema

Introduction Scleral edema is common in scleritis. The sclera is a tissue composed of a small amount of cells and blood vessels, mostly composed of collagen. The surface is covered by the bulbar conjunctiva and the fascia, and it is not in direct contact with the external environment, so it is rarely sick. According to the statistics of most scholars, the incidence rate is only about 0.5% of the total number of patients with eye diseases. Due to the collagen nature of the basic components of the sclera, it is determined that the pathological process is slow and the resulting collagen disorder is difficult to repair. The eyeball is the "window" of collagen, so scleritis is often an ocular manifestation of systemic connective tissue disease.

Cause

The cause of scleritis is unknown. Sometimes the cause is not found. Even the primary site of inflammation is in the sclera, upper sclera, bulbar fascia or other parts of the sputum. For example, posterior scleritis is difficult and acute. Identification of inflammatory pseudotumor.

(1) Exogenous infection

External factors are less common, and can be directly caused by bacteria, viruses, fungi, etc. through conjunctival infections, trauma, surgical wounds, and the like.

(2) Endogenous infection

1. Suppurative metastasis (pyrococcus).

2. Non-suppurative granulomatous (tuberculosis, syphilis, leprosy).

(3) Eye performance of connective tissue diseases

Connective tissue disease (collagen disease) is associated with autoimmune diseases such as rheumatoid arthritis, necrotizing nodular lupus erythematosus, nodular arteritis, sarcoma-like disease (sarcoidosis), Wegener granulomatosis, recurrence Concomitant scleritis, such as chondritis, causes a fibrin-like necrotic change in the sclera, which is essentially similar to connective tissue disease. Other cases such as ankylosing spondylitis, Bencet's disease, dermatomyositis, IgA nephropathy, temporal arteritis, and porphyrin have also been reported as complicated with scleritis. This type of granulomatous change may indicate that the lesion is a locally produced antigen (in a delayed type hypersensitivity reaction) or a circulating immune complex deposited in the eye, inducing an immune response to a type III hypersensitivity reaction. In type III hypersensitivity reactions, vascular responses are the result of the binding of antigenic antibodies to the vessel wall. These complexes deposit on the walls of the small veins and activate complement, causing an acute inflammatory response. Therefore, collagen disease is an autoimmune disease in which the immune mechanism of individual genes is dysregulated, or one of them.

an examination

Related inspection

Ophthalmoscopy, eye examination and CT examination of sclera

Clinical examination:

(a) superficial scleritis

Epithelial scleritis (episcleritis) is inflammation of the surface layer of the sclera (or superficial), mostly located between the limbus to rectus adhesion line between the equator. There is a history of periodic episodes, leaving no traces after healing. Adult men and women can be sick, but women are more common, and most patients have monocular disease.

The cause is often unknown, and it is more common in allergen-induced reactions caused by exogenous antigen antibodies, and other systemic diseases such as metabolic diseases - gout. This disease occurs mostly in women's menstrual period and is also associated with endocrine disorders. Allergic reactions occur easily in the anterior surface sclera, which is mainly composed of collagen fibers and elastic fibers. It is rich in vascular network and lymphatic vessels, and is suitable for accumulation of various immune components.

Episcleritis is clinically divided into two types:

1. Simple episcleitis (simple episcleritis): also known as periodic epithelial scleritis (episcleritis periodica fugax).

The clinical symptoms are the superficial sclera of the lesion and the conjunctiva on the lesion, sudden diffuse hyperemia and edema, reddish hue, congested or fan-shaped, most lesions are confined to a certain quadrant, and a wide range is rare. The superficial sclera of the upper sclera is distorted, but it remains radial, with no purple tone of deep vascular congestion, and no localized nodules.

The disease has periodic recurrence, sudden onset, short duration of attack, and is characterized by several days. Half of the patients have mild pain, but often have a burning sensation and stinging discomfort. Occasionally, due to the iris sphincter and ciliary muscle spasm, the pupil is reduced and temporary myopia. Orbital neurovascular edema can also occur during seizures. Severe cases may be accompanied by periodic migraine, and vision is generally unaffected.

2. Nodular episcleritis Nodular episcleritis is a type of superficial scleritis characterized by localized nodules. Often acute, with red eyes, pain, shame, tears, tenderness and other symptoms. Edema infiltration occurs rapidly on the superficial sclera at the limbus, forming a reddish to flaming red localized nodule. Nodules vary from small to large and several millimeters in diameter. The conjunctiva above the nodule can be pushed freely and has tenderness.

The bulbar conjunctival vascular plexus is congested in the light red lesions, and the fire red is attached to the superficial sclera vascular plexus. It can be distinguished by anterior segment fluorescein angiography.

The nodules are round or elliptical, mostly single, sometimes up to the size of a pea. The nodule is located in the superior sclera, and the nodule can be pushed on the sclera, indicating that it is not related to the deep sclera. The scleral plexus remains normal in the lower part of the nodule.

The course of the disease is about 2 weeks old, the nodule changes from fire red to pink, and the shape is flattened by a circle or an ellipse. Finally, it can be completely absorbed, leaving the surface with a trace of blue-gray. Here, the inflammation can be secondary to other parts of the body. After a nodule subsides, a nodule appears again. Multiple recurrences can last for several months. Due to multiple episodes in different parts, a ring of pigmented rings surrounding the sclera around the cornea can be formed. Eye pain is caused by nighttime, and there is also pain that is not significant. Vision is generally unaffected. Mild keratitis is the only complication of superficial scleritis. If there is shame, tears, it indicates mild keratitis, and it is more common in the corneal margin near the nodules.

(two) scleritis

Scleritis or deep scleritis. It is rarer than superficial scleritis, but it is acute, and often accompanied by cornea and uveitis, it is more serious than superficial scleritis, and the prognosis is poor. Generally, superficial scleritis rarely invades the sclera, and scleritis invades the sclera itself. Scleritis is more common in the anterior sclera of the blood vessels, and the scleritis in the posterior equator is less likely to be seen directly and has fewer vascularities. Scleritis can be divided into anterior scleritis and posterior scleritis. Anterior scleritis is common in scleritis. More common in young people or adults, more women than men, both eyes can be diseased at the same time or at the same time.

Scleritis is mainly caused by endogenous antigen-antibody immune complexes, and is often accompanied by systemic collagen disease, so it belongs to the category of collagen disease and is related to autoimmunity. Benson (1988) attributed immunogenicity to inflammation directly invading collagen itself or the scleral matrix (aminodextran). Patients with primary necrotizing anterior scleritis may have altered tolerance to scleral-specific antigens and have delayed-type hypersensitivity to scleral soluble antigen. The discovery of immune complexes in rheumatoid arthritis is a support for this theory. However, most scleritis is difficult to find the cause.

Anterior scleritis

(1) diffuse anterior scleritis (diffuse anterior scleritis): This disease is the most benign of scleritis, rarely combined with severe systemic diseases.

The clinical symptoms are sudden diffuse hyperemia and swelling of the sclera, and the sclera cannot be ascertained. In severe cases, the conjunctiva can be highly edematous, so it is necessary to drop 1:1000 adrenaline into the conjunctival sac to confirm the presence or absence of deep vascular congestion. Nodule. Diffuse is more likely to spread than nodularity. The extent of the lesion can be limited to one quadrant or occupy the entire anterior eye, and is often associated with scleral epithelial inflammation.

(2) Nodular anterior scleritis: The clinical symptoms are that the conscious eye pain is quite intense and radiates around the eyelids. Half of the patients have eye tenderness. The inflammatory nodules are completely inactive in deep red, but they are clearly defined by the upper scleral tissue. The blood vessels on the surface are raised by the nodules. The nodule can be single or multiple. Invasive nodules can spread around the cornea to form a circular scleritis. At this time, the whole eyeball is dark purple, with gray-white nodules between them, and the sputum is thin after being absorbed. The shorter course of disease can last for several weeks or months, and the elderly can reach several years. The infiltration is gradually absorbed without rupture, and the sclera becomes thin and dark purple or magnetic white. Partial scleral bulging or grape swollen formation due to loss of intraocular pressure. The deep vascular plexus of the upper sclera is purplish red and the blood vessels cannot move. The superficial and deep scleral vascular network, distorted, has a large anastomotic branch between the deep blood vessels, thus showing a bead-like expansion and filling of the blood vessels. If there are symptoms of shame and tearing, keratitis and uveitis should be considered, and the results often seriously impair vision.

(3) necrotizing anterior scleritis: This disease is also known as inflammatory necrotizing scleritis. This type is relatively rare in clinical practice, but it is the most destructive, and it is also a precursor to severe collagen disease. The course of the disease is slow. About half of the patients had complications and decreased vision.

The clinical symptoms are characterized by limited inflammatory infiltration in the early stage of the lesion, sharp congestion in the lesion area, vascular tortuosity and obstruction. Typical manifestations are localized flaky avascular regions. Scleral edema is present below or near the avascular zone, and the superficial blood vessels of the sclera are displaced forward (this sign is easily found with no red light). The development of the lesion can be limited to a small range, and can also develop into a large area of necrosis, or from the periphery of the original lesion to the sides of the eyeball, and finally damage the entire front of the eyeball. After the lesion is cured, the sclera continues to thin, and the uveal pigment is blue-violet, unless the intraocular pressure continues to be as high as 4.0 kPa (30 mmHg), and generally no grape swollen. If the necrotic area is small, the new collagen fibers can repair it. If the conjunctiva above it is damaged, it will produce a concave scar. Eye pain is about half.

(4) scleromalacia perforans: also known as non-inflammatory necrotic scleritis, is a rare type of special type of scleritis, concealed, almost asymptomatic, about half of patients with rheumatoid arthritis or tonicity More arthritis related. Eye disease can precede arthritis. Most of the patients were women over the age of 50. The lesions are bilateral in one eye, but their performance varies. The course of the disease develops slowly, but it also has a sharp performance, leading to blindness within a few weeks.

This disease is rarely associated with inflammation or pain. The lesion is characterized by a yellow or gray spot on the sclera between the limbus and the equator. In the most severe cases, the local sclera gradually becomes carrion-like and becomes necrotic, and the necrotic tissue can completely disappear once the sclera is absent. The blood vessels in the residual scleral tissue are significantly reduced, and appear white enamel from the outside. About half of the patients have more than one necrotic lesion. Scleral defects due to necrosis can be covered by a thin layer of connective tissue that may be derived from the conjunctiva, unless there is an increase in intraocular pressure and no swelling is generally seen. None of them had tenderness in the eyes. One of the corneas is unaffected. There is no tissue regeneration repair in the defect area, which eventually leads to perforation and uveal detachment.

2. Posterior scleritis

Posterior scleritis refers to inflammation that occurs in the posterior equator and around the optic nerve. The severity is sufficient to cause damage to the posterior part of the eyeball. Due to the diversity of the manifestations of the disease and its seldom considered in the diagnosis, the disease is not combined with anterior scleritis, and the external eye has no obvious signs, so the disease is the eye. One of the most easily diagnosed diseases in the department. However, when many eyeballs were removed, it was not uncommon to find an eyeball that had a posterior expansion of primary posterior scleritis or anterior scleritis, indicating clinical concealment of posterior scleritis. This disease is also more common in women than in men, and is common in middle-aged people.

(1) Clinical symptoms: The most common symptoms of posterior scleritis are pain, vision loss, and redness, but some people have no obvious symptoms, or only one of these symptoms. In severe cases, there are eyelid edema, conjunctival edema, eyeball protrusion or diplopia, or both. Symptoms are indistinguishable from eyelid cellulitis. The distinguishing point is that the degree of edema of the disease is more obvious than that of cellulitis, and the eyeball of cellulitis is more prominent than that of posterior scleritis. The pain varies from mild to severe, and some are extremely painful, often proportional to the severity of the involvement of anterior scleritis. The patient may complain that the eyeball itself has pain or pain involving the eyebrows, ankles or ankles.

Vision loss is a common symptom associated with optic nerve retinopathy. Some people complain of visual fatigue caused by myopia reduction or increased hyperopia, which is caused by diffuse thickening of the posterior sclera leading to shortening of the eye axis.

Clinical and pathological aspects can be seen, patients with posterior scleritis have anterior sclera involvement, showing superficial scleral vasodilation, patchy anterior scleritis, nodular anterior scleritis. There is also no eye congestion. However, there is a history of pain and eye congestion, or may have been treated with topical corticosteroids.

Eyeballs, ptosis, and edema of the eyelids can be seen in the periamical sclera, which often spreads to the extraocular muscles or eyelids. Because of extraocular muscle inflammation, there may be eyeball pain or diplopia. These symptoms are combined into what is called peri-scleraitis, scleral bulbar fasciitis, and acute anterior inflammatory pseudotumor.

In addition, there is a lesion that is more superficial, showing obvious ocular fasciitis, while the sclera has no obvious inflammation, which James calls jelly ocular fasciitis. The conjunctiva is semi-gelatinous orange-red edema, such as fish-like, slightly hard to touch, mild depression when pressed, lesions can extend to the limbus, and the eye is still normal. However, there are also serious cases in which the lesion can invade the sclera and become a jelly-like scleritis.

(2) fundus lesions:

1 Clearly defined fundus mass: Localized scleral swelling can cause choroidal bulge. Concentric choroid wrinkles or retinal streaks are usually enclosed. This type of inflammatory nodules is often accompanied by pain around the ankle, but it can also be diseased without obvious symptoms found in routine examinations.

2 choroidal folds, retinal streaks and optic disc edema: this is the main fundus manifestation of scleritis. Patients are often accompanied by mild pain or superficial vascular congestion in the eyelids. Inflammation of the sclera adjacent to the optic disc may cause optic disc edema.

3 annular choroidal detachment: in some cases, a slightly spherical choroidal detachment is seen near the scleritis lesion, but the annular ciliary choroidal detachment is more common.

4 exudative macular detachment: young women with posterior scleritis can cause post-polar blood-retinal detachment, this detachment is limited to the posterior pole. Fundus fluorescein angiography shows multiple leaky areas of tip size. Ultrasound scan revealed thickening of the posterior layer of the eye and edema of the eyeball fascia.

For reasons such as angle-closure glaucoma, choroid wrinkles, optic disc edema, clear-eyed masses, choroidal detachment, etc., the possibility of this disease should be considered.

Differential diagnosis

Symptoms of scleral edema need to be distinguished from the symptoms below.

Limited scleral swelling: posterior scleral staphyloma: When the posterior part of the degenerative myopic eye grows significantly, the posterior pole can produce limited scleral swelling, and the edge can be sloped or steep.

Angle scleral staphyloma: Scleral staphyloma refers to the sclera along with the uvea as a purple-black bulge of the grape. The reason is that the congenital defect or pathological damage of the sclera makes the resistance weakened, and under the action of normal intraocular pressure or high intraocular pressure, the sclera and the uveal bulge outward. According to the range of bulging, it is divided into partial scleral staphyloma and total scleral staphyloma.

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