Scleritis needs to be treated as soon as you notice symptoms to save your vision. Scleritis is a painful inflammation of the white part of the eye and other adjacent structures. Posterior inflammation is usually not visible on exam, and the ophthalmologist can use ultrasound, looking for signs of inflammation behind the eye. https://eyewiki.org/w/index.php?title=Scleritis&oldid=84980. Because scleritis can damage vision if left untreated, it's imperative to get symptoms checked as soon as possible. Treatment. Both scleritis and conjunctivitis cause redness of the eye. Treatments of scleritis aim to reduce inflammation and pain. (October 2010). I found that the compound DMSO in combination with steriod drops seems to be much more effective than steriod drops alone. There are two categories of scleritis: posterior scleritis and anterior scleritis. Scleritis is usually treated with oral anti-inflammatory medications, such as ibuprofen or prescription-strength nonsteroidal anti-inflammatory drugs (NSAIDs). It is common in patients that have an underlying autoimmune disease (e.g. Certain conditions increase the risk of uveitis, but the disease often occurs for no known reason. Copyright 2010 by the American Academy of Family Physicians. Get ophthalmologist-reviewed tips and information about eye health and preserving your vision. When arthritis manifests, it can cause inflammatory diseases such as scleritis. More recently, tumor necrosis factor (TNF) alpha inhibitors such as infliximab have shown promise in the treatment of non-infectious scleritis refractory to other treatment. It is more likely than episcleritis to be associated with an underlying inflammatory condition like rheumatoid arthritis. Its the most common type of scleritis. The most severe can be very painful and destroy the sclera. Riono WP, Hidayat AA and Rao NA. B-scan ultrasonography and orbital magnetic resonance imaging (MRI) may be used for the detection of posterior scleritis. Episcleritis is most common in adults in their 40s and 50s. This can help repair the eye and stop further loss of vision. Case 2. Nodular anterior scleritis. Scleritis is similar to episcleritis in terms of appearance and symptoms. Posterior: This is when the back of your sclera is inflamed. Mild allergic conjunctivitis may be treated with an over-the-counter antihistamine/vasoconstrictor agent, or with a more effective second-generation topical histamine H. Anti-inflammatory agents (e.g., topical cyclosporine [Restasis]), topical corticosteroids, and systemic omega-3 fatty acids are appropriate therapies for moderate dry eye. Topical Steroids These drugs reduce inflammation. 1966;50(8):463-81. It is widespread inflammation of the sclera covering the front part of the eye. 9. Research has shown that 15 percent of cases of scleritis are linked to arthritis. Get ophthalmologist-reviewed tips and information about eye health and preserving your vision. Symptoms of scleritis include pain, redness, tearing, light sensitivity (photophobia), tenderness of the eye, and decreased visual acuity. At one-week follow up, the scleral inflammation had resolved. Scleritis is the inflammation in the episcleral and scleral tissues with injection in both superficial and deep episcleral vessels. Scleritis can be visually significant, depending on the severity and presentation and any associated systemic conditions. Episcleritis and scleritis are inflammatory conditions which affect the eye. (December 2014). There are two types of scleritis, anterior and posterior. Preauricular lymph node involvement and visual acuity must also be assessed. Examples of steroid drops include prednisolone and dexamethasone eye drops. Primary indications for surgical intervention include scleral perforation or the presence of excessive scleral thinning with a high risk of rupture. People with this type of scleritis may have pain and tenderness. Episcleritis is the inflammation of the outer layer of the sclera. Treatment Episcleritis often requires no treatment but in some cases a course of steroid eye drops is required. It is good practice to check for corneal involvement or penetrating injury, and to consider urgent referral to ophthalmology. For the most part, however, episcleritis treatments address the underlying inflammatory conditions. However, one must be prepared to place a scleral reinforcement graft or other patch graft as severe thinning may result in the presentation of intraocular contents. International Society of Refractive Surgery, lupus, or other connective tissue disease, redness and swelling of the white part of the eye, look at the inside and outside of your eye using a, corticosteroid pills (medicine to control inflammation), nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin or ibuprofen for pain and, drugs that weaken or modify the response of the immune system may be used with severe scleritis (immunosuppressive and immunomodulatory drugs). . treatment have been tried with variable success rates, which Their difference arises from the pain you will feel in each instance. Scleritis and/or uveitis sometimes accompanies patients who suffer from rheumatoid arthritis. Episcleritis is defined as inflammation confined the more superficial episcleral tissue. It is often associated with an upper respiratory infection spread through coughing. Chlamydial conjunctivitis should be suspected in sexually active patients who have typical signs and symptoms and do not respond to standard antibacterial treatment.2 Patients with chlamydial infection also may present with chronic follicular conjunctivitis. Treatment for Scleritis Scleritis is best managed by treating the underlying cause. Patients with renal compromise must be warned of renal toxicity. The entire anterior sclera or just a portion may be involved. . Scleritis is a serious inflammatory disease that . Oral non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line agent for mild-to-moderate scleritis. Other signs vary depending on the location of the scleritis and degree of involvement. Depending on the severity of the condition a course of eye drops will last from 2 weeks. Rheumatoid Arthritis Associated Episcleritis and Scleritis: An Update on Treatment Perspectives. Sometimes the white of the eye has a bluish or purplish tinge. Treatment varies depending on the type of scleritis. Cyclosporine is nephrotoxic and thus may be used as adjunct therapy allowing for lower corticosteroid dosing. It also can be linked to issues with your blood vessels (known as vascular disease). American Academy of Ophthalmology. Posterior scleritis, although rare, can manifest as serous retinal detachment, choroidal folds, or both. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. And you may have blurry vision, unexplained tears, or notice that your eyes are especially sensitive to light. Sometimes surgery is needed to treat the complications of scleritis. 0 Shop NowFind Eye Doctor Conditions Conditions Eye Conditions, A-Z Eye Conditions, A-Z Generally, viral and bacterial conjunctivitis are self-limiting conditions, and serious complications are rare. There is often a zonal granulomatous reaction that may be localized or diffuse. Cureus. Perennial allergic conjunctivitis persists throughout the year. 2013 Jan6(1):65-6. doi: 10.4103/0974-620X.111938. Expert Opinion on Pharmacotherapy. Lastly, the doctors will perform a differential diagnosis, like episcleritis diagnosis, to ascertain scleritis caused the eye inflammation. Complications are frequent and include peripheral keratitis, uveitis, cataract and glaucoma. 1. Scleritis.. rheumatoid arthritis) or other disease process. Sclerokeratitis may move centrally gradually and thus opacify a large segment of the cornea. Pulsed intravenous methylprednisolone at 0.5-1g may be required initially for severe scleritis. 55,000 and with additional medicines such as ointments, eye drops, antibiotics et. If the infection does not improve within one week of treatment, the patient should be referred to an ophthalmologist.4,5. Ophthalmology 1999; Jul: 106(7):1328-33. . How long will the gas bubble stay in my eye after retinal detachment treatment? Severe vasculitis as well as infarction and necrosis with exposure of the choroid may result. In general, scleritis is more common in women than men and usually occurs during the fifth decade of life [2]. Others require immediate treatment. How do you treat a wasp sting on the eyelid? There are three types of anterior scleritis. Scleritis is often linked with an autoimmune disease. Some cases only respond to stronger medication, special contact lenses, or eyelid injections. Tear osmolarity is the best single diagnostic test for dry eye.30,31 The overall accuracy of the diagnosis increases when tear osmolarity is combined with assessment of tear turnover rate and evaporation. If you have symptoms of scleritis, you should see anophthalmologist as soon as possible. It can spread to affect the adjacent layers around the sclera, including the episclera and the cornea. (October 2017). Scleritis is an inflammatory ocular disorder within the scleral wall of the eye [].It has been repeatedly reported that a scleritis diagnosis is most often associated with a systemic disease [1,2,3].Previous studies have reported that 40% to 50% of all patients with scleritis have an associated infectious or autoimmune disease; 5% to 10% of them have an infectious disease as the origin, while . Vessels have a reddish hue compared to the deeper-bluish hue in scleritis. Specialists put anterior scleritis into three categories: Nodular anterior scleritis causes abnormal growth of tissue called a nodule, visible on the sclera covering the front part of the eye. (October 1998). (November 2021). Treatments can restore lost vision and prevent further vision loss. We defined baseline as the initiation of tacrolimus eye drops. Anterior: This is when the front of your sclera is inflamed. In scleritis, scleral edema and inflammation are present in all forms of disease. Berchicci L, Miserocchi E, Di Nicola M, et al; Clinical features of patients with episcleritis and scleritis in an Italian tertiary care referral center. They can initially look similar but they do not feel similar and they do not behave similarly. You may need any of the following: . Even if your symptoms improve, it's important to follow up with an ophthalmologist on a . Laboratory testing may be ordered regularly to follow the therapeutic levels of the medication, to monitor for systemic toxicity, or to determine treatment efficacy. With posterior scleritis, you cant usually see these kinds of issues because theyre on the back of the white of your eye. All rights reserved. A severe pain that may involve the eye and orbit is usually present. An eye doctor can give or prescribe lubricating eye drops to soothe the irritation and redness. National Eye Institute. If the disease is inadequately controlled on corticosteroids, immunomodulatory therapy may be necessary. Chronic pain can be debilitating if not treated. It usually occurs in the fourth to sixth decades of life. A meta-analysis based on five randomized controlled trials showed that bacterial conjunctivitis is self-limiting (65 percent of patients improved after two to five days without antibiotic treatment), and that severe complications are rare.2,7,1619 Studies show that bacterial pathogens are isolated from only 50 percent of clinically diagnosed bacterial conjunctivitis cases.8,16 Moreover, the use of antibiotics is associated with increased antibiotic resistance, additional expense for patients, and the medicalization of minor illness.4,2022 Therefore, delaying antibiotic therapy is an option for acute bacterial conjunctivitis in many patients (Table 2).2,9 A shared decision-making approach is appropriate, and many patients are willing to delay antibiotic therapy when counseled about the self-limiting nature of the disease. non-steroidal anti-inflammatory drugs (NSAIDs), Berchicci L, Miserocchi E, Di Nicola M, et al, Red Eye (Causes, Symptoms, and Treatment), It tends to come on more slowly than episcleritis. It also causes eye-swelling in some people. Copyright 2023 American Academy of Family Physicians. Some people only have one type of scleritis, but others can have inflammation at the front and back of the eye. Both can be associated with other conditions such as rheumatoid arthritis and systemic lupus erythematosus (SLE), although this is more likely in the case of scleritis. This pain may radiate to involve the ear, scalp, face and jaw. While scleritis is a severe form of eye inflammation associated with a high risk of vision loss, episcleritis is more benign (less serious and dangerous). Scleritis can affect vision permanently. Hyperacute bacterial conjunctivitis is characterized by copious, purulent discharge; pain; and diminished vision loss. An eye doctor who sees these conditions frequently can tell them apart. When this area is inflamed and hurts, doctors call that condition scleritis. You are at high risk of contracting scleritis if you have autoimmune diseases like arthritis. People with this type of scleritis may have pain and tenderness in the eye. Oman J Ophthalmol. may be normal. Topical NSAIDs have not been shown to have significant benefit over placebo in the treatment of episcleritis.36 Topical steroids may be useful for severe cases. Some of those that are linked to scleritis include: It also can be caused by an eye infection, an injury to your eye, or a fungus or parasite. Expert Opinion on Pharmacotherapy. Corticosteroids may be used in patients unresponsive to COX-inhibitors or those with posterior or necrotizing disease. What could this be? Some doctors treat scleritis with injections of steroid medication into the sclera or around the eye. Okhravi et al. Patients will call the office and describe their eye as being really red, almost purple in color, and swollen. A typical starting dose may be 1mg/kg/day of prednisone. It can help to meet and talk to people who have had a similar experience with their eyes: search online for scleritis and episcleritis support groups. In some cases, people lose some or all of their vision. (November 2021). So, its vitally important to get to the bottom of this uncommon but aggravating condition. However, it is generally a mild condition with no serious consequences. (March 2013). If the inflammation is more severe, steroid eye drops may be prescribed, and sometimes anti-inflammatory tablets are needed also. Your doctor may give you a non-steroidal anti-inflammatory drug (NSAID). Central stromal keratitis may also occur in the absence of treatment. Red-free light with the slit lamp also accentuates the visibility of the blood vessels and areas of capillary nonperfusion. If episcleritis does not settle over a week or if the pain becomes worse and your vision is affected, you should see a doctor in case you have scleritis. Please review our about page for more information. It affects a slightly older age group, usually the fourth to sixth decades of life. Episcleritis and scleritis are inflammatory conditions. In some cases, treatment may be necessary for months to years. During your exam, your ophthalmologist will: Your ophthalmologist may work with your primary care doctor or a rheumatologist (doctor that treats autoimmune diseases) to help diagnose you. When inflammation is the main factor in dry eye, cyclosporine ophthalmic drops (Restasis) may increase tear production.5 Topical cyclosporine may take several months to provide subjective improvement. Atropine sulfate eye ointment (1 time/daily) and 0.1% fluorometholone eye drops (4 times/daily) along with . America Journal of Ophthalmology. Signs and symptoms persist for less than three to four weeks. The white part of your eye (called the sclera) is a layer of tissue that protects the rest of your eye. The condition also typically affects women more than men. . Postoperative Necrotizing Scleritis: A Report of Four Cases. In the diffuse form, anterior scleral edema is present along with dilation of the deep episcleral vessels. TNF-alpha inhibitors may also result in a drug-induced lupus-like syndrome as well as increased risk of lymphoproliferative disease. See permissionsforcopyrightquestions and/or permission requests. The primary goal of treatment of scleritis is to minimize inflammation and thus reduce damage to ocular structures. Necrotising scleritis with inflammation is the most severe and distressing form of scleritis. Statin Therapy Yields Higher Corneal Clarity, Point-Counterpoint: Ultra-Widefield Imaging vs. Dilated Funduscopy. It is relatively cheaper with fewer side effects. Conjunctivitis is the most common cause of red eye. Anterior scleritis, is more common than posterior scleritis. Patients with chronic blepharitis who do not respond adequately to eyelid hygiene and topical antibiotics may benefit from an oral tetracycline or doxycycline. Conjunctivitis is the most common cause of red eye and is one of the leading indications for antibiotics.1 Causes of conjunctivitis may be infectious (e.g., viral, bacterial, chlamydial) or noninfectious (e.g., allergies, irritants).2 Most cases of viral and bacterial conjunctivitis are self-limiting. Seasonal allergic conjunctivitis is the most common form of the condition, and symptoms are related to season-specific aeroallergens. Two or more surgical procedures may be associated with the onset of surgically induced scleritis. Treatment Usually, simple episcleritis will clear up on its own in a week to 10 days. Topical antibiotics are rarely necessary because secondary bacterial infections are uncommon.12. Posterior scleritis is defined as involvement of the sclera posterior to the insertion of the rectus muscles. Another type causes tender nodules (bumps) to appear on the sclera. WebMD does not provide medical advice, diagnosis or treatment. The history should include questions about unilateral or bilateral eye involvement, duration of symptoms, type and amount of discharge, visual changes, severity of pain, photophobia, previous treatments, presence of allergies or systemic disease, and the use of contact lenses. Journal of Clinical Medicine. More Than Meets the Eye: A Rare Case of Posterior Scleritis Masquerading as Orbital Cellulitis. If these treatments don't work then immunosuppressant drugs such as. Home / Eye Conditions & Diseases / Scleritis. A 66-year-old female visited another eye clinic and was diagnosed as . eCollection 2015. Any ophthalmic antibiotic may be considered for the treatment of acute bacterial conjunctivitis because they have similar cure rates. The onset of scleritis is gradual. However, these drops should be used only on special occasions because regular use leads to even more redness (called a rebound effect). Men are more likely to have infectious scleritis than women. Allergic conjunctivitis is often associated with atopic diseases, such as allergic rhinitis (most common), eczema, and asthma.27 Ocular allergies affect an estimated 25 percent of the population in the United States.28 Itching of the eyes is the most apparent feature of allergic conjunctivitis. 2015 Sep-Dec8(3):216. doi: 10.4103/0974-620X.169909. Scleritis is an inflammation of the sclera, the white outer wall of the eye. Episcleritis is often recurrent and can affect one or both eyes. You also might feel tenderness in your eye, along with pain that goes from your eye to your jaw, face, or head. Journal Francais dophtalmologie. Simple annoyance or the sign of a problem? It tends to come on quickly. Topical aminoglycosides should be avoided because they are toxic to corneal epi-thelium.34 Studies show that eye patches do not improve patient comfort or healing of corneal abrasion.35 All steroid preparations are contraindicated in patients with corneal abrasion. Systemic lupus erythematous may present with a malar rash, photosensitivity, pleuritis, pericarditis and seizures. American Academy of Ophthalmology. Among the suggested treatments are topical steroids, oral NSAIDs and corticosteroids. . Mild cases of keratopathy usually clear up with eye drops or medicated eye ointment. Eur J Ophthalmol. An example of such a drug is bisphosphonates, a cure for osteoporosis. But common causes include having an autoimmune disease such as arthritis or having a post-surgical reaction. Ophthalmology. If localized, it may result in near total loss of scleral tissue in that region. Ibuprofen and indomethacin are often Scleritis is severe inflammation of the sclera (the white outer area of the eye). They also have eye pain. Treatment will vary depending on the type of scleritis, and can include: Steroid eye drops Anti-inflammation medications, such as nonsteroidal anti-inflammatories or corticosteroids (prednisone) Oral antibiotic or antiviral drugs There is an increase in inflammatory cells including T-cells of all types and macrophages. How can I make a broken blood vessel in my eye heal faster? American Academy of Ophthalmology. Scleritis. Scleritis associated with autoimmune disease is characterized by zonal necrosis of the sclera surrounded by granulomatous inflammation and vasculitis. A branching pattern of staining suggests HSV infection or a healing abrasion. Implants. Several treatment options are available. Al-Amry M; Nodular episcleritis after laser in situ keratomileusis in patient with systemic lupus erythematosus. Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. Steroid (cortisone derived) eye drops may also help the symptoms in some patients. These drugs reduce inflammation. Drugs used to treat scleritis include a corticosteroid solution that you apply directly to your eye, an oral corticosteroid ( prednisone) and a non-steroidal anti-inflammatory drug (NSAID). As there are different forms of scleritis, the pathophysiology is also varied. In infective scleritis, if infective agent is identified, topical or . Polymerase chain reaction testing of conjunctival scrapings is diagnostic, but is not usually needed. Parentin F, Lepore L, Rabach I, et al; Paediatric Behcet's disease presenting with recurrent papillitis and episcleritis: a case report. If artificial tears cause itching or irritation, it may be necessary to switch to a preservative-free form or an alternative preparation. Rarely, it is caused by a fungus or a parasite. With posterior scleritis, there may be chorioretinal granulomas, retinal vasculitis, serous retinal detachment and optic nerve edema with or without cotton-wool spots. There are many connective tissue disorders that are associated with scleral disease. Episcleritis is a more superficial inflammation that can be treated with topical medications, such as nonsteroidal eye drops. Scleritis Scleritis The sclera is the white outer wall of the eye. Although scleritis and episcleritis each cause inflammation of the eyes and present with almost the same symptoms, they are two entirely different diseases. If the patient is taking warfarin (Coumadin), the International Normalized Ratio should be checked. Scleritis may be active for several months or years before going into long-term remission. It is harmless, with blood reabsorption over a few weeks, and no treatment is needed. There is no known HLA association. However, scleritis is usually much more painful, and it can lead to vision loss due to progressive inflammation of the ocular tissues or even morbidity and mortality due to an underlying collagen vascular disease. Epub 2013 Nov 12. Scleritis Treatment If scleritis is diagnosed, immediate treatment will be necessary. Over-the-counter antihistamine/vasoconstrictor agents are effective in treating mild allergic conjunctivitis. Patients with granulomatosis with polyangiitis may require cyclosphosphamide or mycophenolate. Scleritis typically occurs in patients 30-60 years old and is rare in children . . Red eye is the cardinal sign of ocular inflammation. The eyes may water a little and the eye may be a little tender when pressure is applied over the red area. Adjustment of medications and dosages is based on the level of clinical response. In addition to complete physical examination, laboratory studies should include assessment of blood pressure, renal function, and acute phase response. Patient is a UK registered trade mark. Subconjunctival hemorrhage is diagnosed clinically. Some patients with dry eye may have ocular discomfort without tear film abnormality on examination. Doctors predominantly prescribe them to their patients who are living with arthritis. Try our Symptom Checker Got any other symptoms? Warm compresses and ophthalmic lubricants (e.g., hydroxypropyl cellulose [Lacrisert], methylcellulose [Murocel], artificial tears) may relieve symptoms. Scleritis may be linked to: Scleritis may be caused by trauma (injury) to the eye. These inflammatory conditions cannot be directly prevented. The cost of treatment depends on the type of inflammation and also the type of scleritis. The white part of the eye (sclera) swells and reddens. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. As scleritis is associated with systemic autoimmune diseases, it is more common in women. Scleritis tends to be very painful, causing a deep 'boring' kind of pain in or around the eye: that's how it is distinguished from episcleritis which is uncomfortable but not that painful. It's not known what triggers the inflammation, which seems to start in the small blood vessels running on the surface of the eye. Recognizing the need for emergent referral to an ophthalmologist is key in the primary care management of red eye. Scleritis is a severe inflammation of the white part of the eye. This page has been accessed 416,937 times. Br J Ophthalmol. Causes Scleritis is often linked to autoimmune diseases. Visual loss is related to the severity of the scleritis. Most patients develop severe boring or piercing eye pain over several days. American Academy of Ophthalmology: Scleritis Diagnosis, Scleritis Treatment, What is Scleritis? Causes.. Vessels blanch with phenylephrine drops and can be moved by a cotton swab. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Episodes may be recurrent. NSAIDS that are selective COX-2 inhibitors may have fewer GI side effects but may have more cardiovascular side effects. There are additional images of types of scleritis in Further Reading below. The sclera is the . The most common form, anterior scleritis, is defined as scleral inflammation anterior to the extraocular recti muscles. Medical disclaimer. It may also be infectious or surgically/trauma-induced. Often, though, scleritis has no identifiable cause. The management will depend on what type of scleritis this is and on its severity. 10,000 to Rs. Canadian Family Physician. However, we will follow up with suggested ways to find appropriate information related to your question. While rare, scleritis can develop due to medication side effects, infection, or autoimmune diseases such as Lyme's or Rheumatoid arthritis. There are several types of scleritis, depending on what part of the eye is affected and how inflamed the tissues are: Episcleritis does not necessarily need any treatment. Both choroidal exposure and staphyloma formation may occur. This dose should be tapered to the best-tolerated dose. 2000 Oct130(4):469-76. Episcleritis does not cause scleritis, although scleritis can lead to associated episcleritis. 2005 - 2023 WebMD LLC. Scleritis is severe pain, tenderness, swelling, and redness of the sclera. Sclerokeratitis in which peripheral cornea is opacified by fibrosis and lipid deposition with neighboring scleritis may occur particularly with herpes zoster scleritis. The primary goal of treatment of scleritis is to minimize inflammation and thus reduce damage to ocular structures. etc.) though evidence suggests that treatment of non-necrotizing scleritis with . They are the only eye doctors with access to all diagnostic and treatment options for all eye diseases. You may need an additional visit with a primary care doctor or rheumatologist to perform blood tests or X-rays to uncover a related underlying medical condition. 2012 Dec;88(1046):713-8. Canadian Family Physician. Ophthalmology referral is indicated if the patient needs topical steroid therapy or surgical procedures. Scleritis is less common, affecting only about 4 people per 100,000 per year. There isnt always an obvious reason it happens, but most of the time, its caused by an autoimmune disorder (when your bodys defense system attacks its own tissues). Certain types of uveitis can return after treatment. Early treatment is important. These may cause temporary blurred vision. These steroids help treat mild scleritis, causing less severe side effects. Some of the new 'biological agents' such as rituximab can also be effective. and omeprazole (20 mg/d) to counter the side effects of steroid treatment. Microabscesses may be found in addition to necrotizing inflammation in infectious scleritis. What are the possible complications of episcleritis and scleritis? Treatment includes frequent applications of artificial tears throughout the day and nightly application of lubricant ointments, which reduce the rate of tear evaporation. Related letter: "Features and Serotypes of Chlamydial Conjunctivitis.". These superficial vessels blanch with 2.5-10% phenylephrine while deeper vessels are unaffected.
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