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Episcleritis Associated with Lyme Disease

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Title: Episcleritis Associated with Lyme Disease, Case Report

Author: Eliza Barnwell, MSCR

Photographer: unknown

Date: 9/19/16

Slit-lamp photograph showing dilated and injected episcleral vessels.

Same patient 5 minutes post-application of 2.5% phenylephrine.

Secondary CORE Category:  Intraocular Inflammation and Uveitis / Noninfections (Autoimmune) Uveitis

Keywords / Main Subjects: Episcleritis; scleritis; conjunctival inflammation

Diagnosis: Episcleritis

Description of Image:  This patient is a 24–year-old male with a one year history of Lyme disease who presented with 2 months of light sensitivity, redness and irritation in the right eye.  Slit-lamp examination of the right eye revealed mild ptosis, 2+ sectoral injection of the conjunctiva in the superior and nasal regions with dilated episcleral vessels and 3 cells per high-powered-field in the anterior chamber.  Examination of his left eye was normal.  Topical application of 2.5% phenylephrine blanched the injected vessels.  He was started on prednisolone drops 4 times a day and the episcleritis resolved shortly thereafter.

Episcleritis is typically an idiopathic, autoimmune condition causing dilation and inflammation of the superficial layers of the eye.1 Although usually idiopathic, episcleritis can also be associated with a variety of systemic diseases such as rheumatoid arthritis, Systemic Lupus Erythematous (SLE) and Inflammatory bowel diseases (IBD).3  Though uncommon, a number of studies have described episcleritis as an ocular manifestation of Lyme disease, both in late and early stages of the disease.4,5,6 In one case report, initiation of intravenous ceftriaxone therapy aggravated episcleral inflammation and caused an anterior chamber reaction in a patient with positive serum titers for Lyme.7

Scleritis is a deeper inflammation of the scleral vessels that typically does not blanch with application of topical phenylephrine.  It is often associated with a systemic autoimmune disease in contrast to episcleritis.  Scleritis tends to have dramatic focal tenderness and in its more severe form can lead to scleral thinning and perforation.

Treatment for scleritis commonly involves systemic anti-inflammatory and immunosuppressive agents, while episcleritis often resolves on its own or can be treated with a short course of topical steroids versus oral NSAIDs.2

Format: image

Identifier: Moran_CORE_23749

References:

  1. Jabs DA, Mudun A, Dunn JP, Marsh MJ. “Episcleritis and scleritis: clinical features and treatment results.” American journal of ophthalmology. 2000;130(4):469-76.
  2. Kirkwood BJ, Kirkwood RA. “Episcleritis and scleritis.” Insight. 2010;35(4):5.
  3. Akpek EK, Uy HS, Christen W, Gurdal C, Foster CS. “Severity of episcleritis and systemic disease association.” Ophthalmology. 1999;106(4):729-31.
  4. Flach AJ, Lavoie PE. “Episcleritis, conjunctivitis, and keratitis as ocular manifestations of Lyme disease.” Ophthalmology. 1990;97(8):973-5.
  5. de la Maza MS, Molina N, Gonzalez-Gonzalez LA, Doctor PP, Tauber J, Foster CS. “Clinical characteristics of a large cohort of patients with scleritis and episcleritis.” Ophthalmology. 2012;119(1):43-50.
  6. Zaidman GW. “Episcleritis and symblepharon associated with Lyme keratitis. American journal of ophthalmology. 1990;109(4):487-8.
  7. Mikkilä HO, Seppälä IJ, Viljanen MK, Peltomaa MP, Karma A. “The expanding clinical spectrum of ocular lyme” Ophthalmology. 2000;107(3):581-7.

Faculty Approval By: Dr. Amy Lin, Dr. Severin Pouly and Dr. Griffin Jardine