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Ophthalmology Spot Diagnosis: Nodular Episcleritis

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A slightly tender and mobile elevated nodule with epithelial injection is typical for nodular episcleritis

This is a case of nodular episcleritis.

Definition of Episcleritis: Episcleritis is defined as the benign recurrent inflammation of episclera and tenon’s capsule.

Types of Episcleritis:

  1. Diffuse episcleritis
  2. Nodular episcleritis

Epidemiology:

  1. Common in females compared to males
  2. Common in young adults

Etiology:

  1. Non-specific immune response to irritants
  2. Idiopathic (mostly)
  3. Rheumatoid arthritis (RA)
  4. Sjogren’s syndrome
  5. Systemic Lupus Erythematosus (SLE)
  6. Herpes Zoster
  7. Tuberculosis
  8. Syphilis
  9. Coccidiodomycosis
  10. Rosacea

Differential diagnoses:

  1. Phlycten
  2. Inflamed piguecula
  3. Scleritis
  4. Sclerosing keratitis

Episcleritis periodica fugax: Fleeting and repeated attacks of episcleritis

Distinguishing Episcleritis from Scleritis:

Points Nodular episcleritis Nodular scleritis
Pain/Tenderness Mild Severe, generalized, periocular
Injection Affects superficial episcleral plexus Affects deep sclera plexus
2.5% phenylephrine Blanches Untouched
Color of involved site Bright red Bluish or dusky
Nodule Conjunctiva freely mobile over it and traversed by vessels Diffuse and fixed
Scleral affection No Yes, repeated attacks may lead to necrosis and ectasia
Corneal complications Minimal Seen in 30-40% cases
Uveitis Occasional mild iritis Present in 30% cases

Treatment of Episcleritis:

  1. Artificial tears and/or Topical vasoconstrictor antihistamine drop (naphazoline/pheniramine)
  2. Unresponsive cases: Mild steroid drop
  3. Rarely, oral NSAID may be needed

Note: Warn the patient that episcleritis can recur.

Anatomy of Episclera and Sclera:

Episclera Sclera
Character “Above” sclera Collagen and proteoglycan in criss-corss arrangement
Loose vascular complex between conjunctiva and sclera within Tenon’s capsule Thickness: 1-1.35 mm near optic nerve and thins anteriorly (thinnest immediately behind extraocular muscle insertion)
Superficial and deep plexus (from anterior and posterior ciliary arteries)
  1. Superficial = radial arrangement
  2. Deep = Non-radial arrangement
 AvascularHave endothelial pumps

 

Posteriorly continuous with dural sheath
Functions As synovial membrane for smooth movement of eye Protective covering
Nutrition to avascular sclera Blocks extraneous light to enter globe
Site of insertion of Extraocular muscles
Involvement Nearly always in Scleritis Never in Episcleritis

Scleritis: It is the chronic inflammation of sclera proper and is rarer than episcleritis. It is more common in females and elderly patients (40-70 years). The causes of scleritis are:

  1. Collagen vascular disorders: Rheumatoid arthritis, Polyarteritis nodosa, Wegner’s granulomatosis, SLE, Ankylosing spondylitis
  2. Metabolic: Gout, thyrotoxicosis
  3. Infections: Herpes zoster ophthalmicus, Chronic staphylococcal or streptococcal
  4. Granulomatous: Tuberculosis, Syphilis, Sarcoidosis, Leprosy
  5. Miscellanous: Chemical burns, VKH syndrome, Bechet’s disease, Rosacea
  6. Surgical
  7. Idiopathic

Types of scleritis:

A. Anterior scleritis:

  1. Non-necrotizing (commonest): Diffuse or nodular
  2. Necrotizing:
    • with inflammation: severe pain, choroid visible through transparent sclera
    • without inflammation (scleromalacia perforans): usually asymptomatic and associated with rheumatoid arthritis; uveal dehiscence and globe rupture with minor trauma

B. Posterior scleritis: Usually not associated with systemic disease

Investigations: ESR, Chest X-ray, RF, VDRL, ANA, serum uric acid, mantoux test, USG-B scan (to detect posterior scleritis) etc.

Complications:

Differential diagnosis:

Treatment:

Local and General: Topical steroids, atropine, hot fomentation

If infectious, culture and treat as appropriate

If non-infectious:

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