November 2014 Online Photo Diagnosis

By William Townsend, OD, FAAO, & Jessica K. Lantz

This image shows the left eye of a 42-year-old white female patient who reported that her eye had become red and painful the previous day. On the day that her symptoms began, she had been outside in very windy conditions and reported that a possible foreign body had blown into her eye. Her symptoms increased in severity over time. The patient instilled Visine (Pfizer), which caused burning but did not improve her symptoms.

Past ocular history included LASIK with accompanying postoperative dry eye and superficial punctate keratitis. The patient was taking ibuprofen as needed for ocular discomfort. Her presenting unaided acuities were 20/25 in the right eye and 20/20 in the (affected) left eye. Slit lamp exam was unremarkable in the right eye. In the left eye we noted an elevated, flesh-colored nodule surrounded by sectoral injection of the episcleral and conjunctival vasculature; the nodule stained with fluorescein (Figure 1). There was no corneal involvement, and the anterior chamber was deep and quiet. Pupils were round and reactive with no afferent pupillary defect.

We diagnosed the patient with nodular episcleritis. As there were no contraindications, we prescribed prednisolone acetate ophthalmic suspension 1% every six hours. At her follow-up exam three days later, there was significant improvement in redness and pain, and the nodule had decreased in size and elevation. We provided the patient with a schedule for tapering the steroid drop over the next six days. We also educated the patient regarding the potential for recurrence of episcleritis and encouraged her to make an appointment if she experienced similar signs and symptoms.

Episcleritis Signs and Symptoms

Episcleritis is an inflammatory condition of the episclera characterized by dilation of vasculature and associated redness. The episclera is a fibroelastic tissue located between the clear conjunctiva and the white sclera.⁵ The episclera forms Tenon’s capsule and acts as a synovial membrane that promotes smooth ocular movement.⁵

Episcleritis is a common cause of eye redness and may be incorrectly attributed to an infectious etiology. Correctly identifying episcleritis can reduce healthcare costs and lead to faster recovery for patients. Individuals who experience recurrent episcleritis may require additional systemic testing because it may be linked to an occult underlying condition.

The true frequency of episcleritis is difficult to determine because many individuals who have the condition may not consult a healthcare provider.¹ Episcleritis is more common in females in their fourth or fifth decade of life.⁵ The etiology of episcleritis is often idiopathic^1,2; however, approximately 30% of patients who have this condition have an associated underlying systemic condition.^5,6 Systemic conditions commonly associated with episcleritis include rheumatoid arthritis^1,5, atopy^1,2,5, systemic lupus erythematosus^1,5, seronegative spondyloarthropathies, polyarteritis nodosa⁵, gout^2,5,6, thyroid disease², rosacea^2,6, ocular foreign bodies, penicillin sensitivity, and exposure to industrial solvents.⁶ Episcleritis has been associated with several infectious agents including bacteria⁵ (syphilis⁶ and tuberculosis⁶), viruses⁵ (herpes zoster^2,6), or fungi.⁵ Other conditions linked to episcleritis include inflammatory bowel disease¹, psoriasis³, relapsing polychondritis, Cogan’s syndrome, and Wegener’s granulomatosis.¹

Episcleritis occurs in two forms: simple or nodular. Simple episcleritis is often identified by diffuse sectoral injection in 70% of cases.⁶ Gray infiltrates may be present that have a yellow appearance under red-free illumination.⁶ The natural course of simple episcleritis is characterized by significant symptom reduction in one week, with resolution at around three weeks.⁶ Tenderness to the touch is uncommon in this form of episcleritis.⁶

The second form, nodular episcleritis, is characterized by lymphocytic infiltration and edema localized to one location.⁶ It commonly causes sectoral injection.⁶ Uveitis is present in 10% of cases, and there may be associated corneal involvement.⁶ Tenderness is common, and recovery can take significantly longer compared to simple episcleritis.⁶ The nodular form is characterized by increased symptoms and nodule size during the first week.⁶ Untreated nodular episcleritis may take up to two months for complete resolution.⁶ Recurrent nodular episcleritis may cause changes to underlying sclera, rendering it translucent in appearance.⁵

It is important to differentiate suspected episcleritis from conjunctivitis (inflammation of the clear layer overlying the episclera) and scleritis (inflammation of the white portion of the eye). Significant risk factors for scleritis include increasing age (median age 56 years of age), female gender (60%), and rheumatoid arthritis (29%).³ Pain is often intense and radiates, while the sclera may have a bluish tint during white light examination.² Scleritis often presents with injection of all layers, including the conjunctiva, episclera, and sclera.² Upon instillation of 2.5% phenylepherine, scleral vasculature does not blanch, whereas episcleral and conjunctival vasculature demonstrate vasoconstriction.² Differentiating vascular involvement may also be possible by instilling topical anesthetic and moving the conjunctiva with a cotton tip applicator to determine the depth of the injected vessels.²

Managing Episcleritis

The overall prognosis for resolution of episcleritis is excellent, but more severe or recurrent presentations may require more aggressive treatment and additional testing for underlying systemic conditions.^2,5 Treating episcleritis is often not necessary, as it may spontaneously resolve on its own.⁶ In milder cases, artificial tears and cold compresses may be sufficient palliative measures², but moderate-to-severe cases may require administration of topical steroids² to reduce inflammation, improve patient comfort, and speed recovery. Topical or oral² nonsteroidal anti-inflammatory drugs may be indicated for patients bothered by the pain or when topical steroid use is contraindicated.⁶ Unfortunately, these agents may be of minimal benefit in the treatment of episcleritis.^1,4 Vasoconstricting drops can be utilized to reduce redness, but do not reduce the underlying pathology; in some instances they may actually cause a “rebound effect,” leading to increased redness.⁶

Follow up in managing episcleritis is not necessarily indicated unless topical steroids are prescribed.² With steroid treatment, appropriate follow-up intervals of at least every two to three weeks is indicated until the signs and symptoms resolve and the steroids are discontinued.²

In patients who have recurrent episcleritis or an underlying systemic condition is suspected, additional testing may be indicated.^2,5 Common lab tests for episcleritis may include a chest X-ray,⁵ rheumatoid factor (RF),^2,5 antinuclear antibody (ANA),^2,5 serum uric acid (suspected gout),^5,6 erythrocyte sedimentation rate (ESR),^2,6 and, in suspected cases of syphilis, fluorescent treponemal anti-body absorption test (FTA-ABS),^2,5 microhemagglutionation assay for treponema pallidum antibodies (MHA-TP)^2,5 and rapid plasma reagin (RPR).²

Our patient presented with a classic case of nodular episcleritis accompanied by sectoral injection and moderate pain. A short course of a topical steroid was effective in expediting the recovery and reducing discomfort. We believe that her episcleritis may have been triggered by a foreign substance being blown into her eye on a windy West Texas day. If she presents in the future with recurrent episcleritis, we would consider additional testing.

Dr. Townsend practices in Canyon, Texas, and is an adjunct professor at the University of Houston College of Optometry. He is president of the Ocular Surface Society of Optometry and conducts research in ocular surface disease, lens care solutions, and medications. He is also an advisor to Alcon, B+L, CooperVision, Tearlab Corporation, and Vistakon. Contact him at drbilltownsend@gmail.com. Jessica Lantz is a fourth-year optometry student at the University of Houston College of Optometry.

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