Managing A Case of Recurrent Episcleritis
BY LEO SEMES, OD, FAAO
I had managed a 63-year-old patient's refractive status and monitored her ocular health for more than six years when she presented for an unanticipated visit complaining of a red right eye. She stated that it was mild, had begun several days earlier, didn't hurt or affect her vision and that it had never happened before.
Her vision was correctable to 20/20 in each eye. Intraocular pressure was 13mmHg in each eye. The anterior chamber was free from cells and flare and the pupils reacted normally to light. There was mild sectoral conjunctival and episcleral injection but no perilimbal flush. The cornea did not stain with fluorescein dye.
The diagnosis was straightforward — acute anterior episcleritis. I prescribed Pred Forte (prednisolone acetate 1%, Allergan) to be administered every four hours while awake. I asked her to return in one week for re-evaluation.
At that visit, the conjunctivaland episcleral injection was resolving. The IOP remained at 13mmHg and there was no anterior chamber reaction. I asked her to continue the Pred Forte and to return in one week. At that visit, the episcleritis was completely resolved and IOP remained at 13mmHg in each eye. I asked her to return in 12 months for her regularly scheduled examination.
She returned in approximately six months with history and findings similar to the beginning of the most recent series of visits. I managed her in the same fashion and she responded similarly. She had a second relapse within another nine months for which she was treated and responded similarly. With the third episode, I consulted her internist to consider investigating systemic connections to the now recurrent condition.
Identification and Treatment
Recurrent episcleritis is characterized by repeated episodes of conjunctival injection overlying scleral inflammation. You can differentiate it by slit lamp observation or by using 0.125% phenylephrine (or similar weak adrenergic agonist) to constrict the overlying conjunctival blood vessels. Direct treatment toward resolving the inflammation as there is usually little discomfort or other tissue involvement.
About half of recurrent episcleritis cases have an identifiable systemic association. The most common include connective tissue, vascular inflammatory and infectious causes. Statistics show most cases occur in females.
In this case, laboratory investigation ruled out the prominent causes. Her final diagnosis became idiopathic recurrent episcleritis. She has been maintained on Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch & Lomb) for the past 18 months without incident. We monitor her IOP on a fourmonth schedule, and no episcleritis episodes have occurred.
There are several differential diagnoses for episcleritis. These include inflamed pinguecula, subconjunctival hemorrhage, conjunctivitis, blepharitis, keratitis, scleritis, acute anterior uveitis and acute angle-closure glaucoma. The sectoral injection involving conjunctiva and episcleral vessels was characteristic in this case. Some patients won't attend for treatment and resolve spontaneously within seven to 10 days.
In recurring cases, it's prudent to rule out underlying systemic involvement. There were no identified etiologies in this case. I've maintained the patient on an ester-based steroid (qd) to minimize the possibility of recurrence, but used Pred Forte to quell the initial attack in each case.
Monitoring IOP, even in the case of loteprednol's minimal potential of IOP elevation, is an important aspect of management as well. CLS
Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.