Optometry case study: Nodular episcleritis

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Figure 2. Resolution of signs after 7 days of topical corticosteroid treatment

By Tyson Xu, Specsavers Nowra, NSW

History

Px: 44-year-old Caucasian female
Reason for visit: Foreign body sensation, irritation and redness in RE upon waking the day prior to presentation. Slightly watery but no discharge. Saw GP, who recommended an eye test for definitive diagnosis. No treatment was given.
GH: Nil
Meds: Nil
POH: Nil
FOH: Nil

Clinical Assessment

Unaided VA: R 6/6           L 6/6
Pupils:
 PERRL and no RAPD
Motility: Full and smooth
Confrontation fields:
 R Full          L Full
IOP:
 R 14mmHg L 14mmHg @ 3:40pm

Anterior eye examination:

Figure 1. Day 1 – Sectoral hyperaemia with focal elevated area highlighted by fluorescein staining
  • Sectoral hyperaemia of temporal bulbar conjunctiva in the RE (Figure 1)
    • Focal elevated area highlighted by sodium fluorescein staining
    • Manual displacement of conjunctiva with cotton bud revealed the level of dilated blood vessels as posterior to the conjunctiva
  • Cornea clear with no epithelial defects
  • No anterior chamber cells or flare
  • No abnormalities detected in LE

Fundus examination:

  • No abnormalities detected

Diagnosis & Management

Diagnosis: Episcleritis – nodular

Differential diagnosis:

  • Conjunctivitis
  • Scleritis
  • Acute anterior uveitis
  • Pingueculitis
  • Phlyctenular keratoconjunctivitis
  • Subconjunctival haemorrhage
  • Prominent episcleral vessels (sentinel vessels)

Management:

Figure 2. Resolution of signs after 7 days of topical corticosteroid treatment
  • Due to the symptomatic nature of the patient, topical corticosteroid therapy was initiated with fluorometholone alcohol suspension (FML 0.1%) – one drop every four hours in the RE only. Shaking and refrigeration of the bottle as well as preservative-free lubricant eye drops were also recommended.
  • At the 48-hour review, there was marked improvement of signs and symptoms. As some hyperaemia was still present, topical therapy was continued under the same regime with another review arranged in five days.
  • At the next review, the patient reported resolution of all symptoms and the bulbar conjunctiva was now white and quiet (Figure 2). The patient was advised to taper the treatment according to the following schedule; one drop 2x/day for one week and then one drop 1x/day for one more week.
  • A full eye exam was then scheduled in two weeks where the eye remained white and quiet. The patient was advised no further follow-up was necessary and informed that it may recur.
  • IOP remained stable at each follow-up visit.

Discussion

Episcleritis is the inflammation of the episclera, which is posterior to the conjunctiva but anterior to the sclera. It is a relatively common condition and is typically benign, idiopathic, self-limiting and unilateral, and more prevalent in young females. There are two types of episcleritis: simple and nodular.

Patients with nodular episcleritis present with a focal conjunctival elevation within the dilated blood vessels and are more symptomatic, which is why topical treatment is often initiated. In terms of treatment options, clinical trials have shown that NSAID and artificial tear eye drops alone are inferior to corticosteroid drops in achieving resolution of inflammation in episcleritis.

However, as corticosteroid eye drops can cause ocular side effects such as elevated IOP, posterior subcapsular cataracts and secondary ocular infections, monitoring is essential. Episcleritis can also sometimes progress to scleritis, further highlighting the importance of reviews.

Recurrence is another complication and may indicate an underlying systemic inflammatory cause such as rosacea, atopy or rheumatoid arthritis. Thus, in recurrent presentations, a report to the GP for medical evaluation is warranted.


REFERENCES

  1. Lyons, C.J. Hakin, K.N. Watson, P.G. Topical flurbiprofen: an effective treatment for episcleritis? 4(Pt 3):521‐5. 1990.
  2. Williams, C.P. Browning, A.C. Sleep, T.J. Webber, S.K. McGill, J.C. A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis. Eye. 19(7): 739‐42, 2005 Jul.
  3. Kanski, J. J. (2007). Clinical Ophthalmology A Systematic Approach. Butterworth Heinemann Elsevier. 11: 323‐325.
  4. Gerstenblith ATR, M. (ed.): The Wills Eye Manual. Office and Emergency Room Diagnosis and Treatment of Eye Disease, Sixth Edition edn: Lippincott Williams and Wilkins; 2012
  5. Weiner, G. (2018). Savvy Steroid Use. Available online at https://www.aao.org/eyenet/article/savvy-steroid-use
  6. White, G.E. Episcleritis and Scleritis. Optometry Clinics. 1 (4): 79‐87, 1991
  7. Bruce, A.S. Loughnan, M.S. Anterior Eye disease and therapeutics A‐Z. 2002. Page 118.
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