Case report: Medical and surgical management of presumed canine nodular granulomatous episcleritis with progression to posterior nodular scleritis, choroiditis, and optic neuritis.

Nodular granulomatous episcleritis (NGE) typically presents as an elevated mass or elevated masses at the limbus and often infiltrates the cornea (episclerokeratitis). In the current report, a granulomatous lesion was observed subretinally in the right eye (OD) of a 5-year-old male castrated American Staffordshire Terrier dog. There was concurrent retinal hemorrhage and detachment OD; the right eye was not visual. Due to poor prognosis for vision and potential for a neoplastic etiology of the mass, staging with higher imaging was recommended but declined by the owner. Therefore, an enucleation was performed. Histopathology of the globe identified a subretinal mass, marked histiocytic and lesser lymphoplasmacytic choroiditis, posterior episcleritis, and optic neuritis with retinal detachment. The subretinal mass was composed of densely packed, large, spindle histiocytes mixed with occasional lymphocytes, plasma cells, and only rare neutrophils. Regions of the mass showed lymphocytes aggregate to form nodules. This histological presentation was a type of proliferative histiocytic disease with similarities to nodular granulomatous episcleritis or granulomatous/necrotizing scleritis. This is a novel presentation of NGE-like progression to subretinal scleral, choroidal, and retinal involvement and provides a new differential possibility for posterior segment masses observed on fundic examination.

Clinical and pathological findings in five dogs with nodular histiocytic iritis in the United Kingdom: A case series.

PURPOSE: The aim of this study was to describe the clinical presentation, histopathology, management, and outcome of nodular histiocytic iritis, an intraocular variant of nodular granulomatous episcleritis (NGE). METHODS: A retrospective review of the medical records of five dogs with intraocular NGE-type inflammation as diagnosed by histopathology. RESULTS: Four Border Collies and one crossbreed dog, aged 1.5-3.4 years (mean age 2.38 years). The clinical presentation was an extensive, raised, pale iris lesion of variable location. All cases were unilateral. The physical examination was normal. Complete blood count/serum biochemistry (n = 1) and thoracic radiography (n = 1) were normal. Ocular ultrasound (n = 2) was normal apart from increased iris thickness. Enucleation (n = 4) or excisional biopsy (iridectomy, n = 1) was performed because of suspected neoplasia. Following enucleation, the remaining, contralateral eye did not develop additional lesions (9 days-3.7 years follow-up). There was no recurrence following sector iridectomy with 5 months topical 1% prednisolone acetate (3.9 years follow-up). The histopathologic findings in all five cases indicated a focal histiocytic and lymphoplasmacytic anterior uveitis (iritis), similar to that seen in cases of NGE. CONCLUSION: Nodular histiocytic iritis presents as unilateral iris thickening in isolation and young Collies appear to be predisposed. The histopathological findings are similar to NGE. Although the clinical presentation resembles intraocular neoplasia, an inflammatory process should be considered, which may be amenable to medical management. Definitive diagnosis may be obtained by iris sampling.

Ocular manifestations of granulomatosis with polyangiitis: report from a tertiary eye care center.

PURPOSE: To report demographic characteristics and ophthalmological manifestations of patients with granulomatosis with polyangiitis (GPA) in a tertiary eye care center in Turkey. METHODS: Medical records of patients with GPA-related ocular manifestations evaluated between 2013 and 2023 were included. Demographic and clinical characteristics of the patients including nature of systemic involvement, ophthalmologic symptoms and signs, laboratory investigations and treatment modality were reviewed. RESULTS: Twelve eyes of 10 patients (5 female/5 male) were included. The mean age was 57.2 ± 12.2 (35-71) years. Five (50%) patients were already diagnosed with GPA. Ocular involvement was the first manifestation of GPA in 3 patients. The remaining 2 patients had simultaneous systemic and ocular symptoms at presentation. Conjunctival hyperemia (9 eyes) and pain (7 eyes) were the most frequent presenting symptoms followed by blurred vision (3 eyes). The frequencies of ocular manifestations were as follows:episcleritis (3 eyes), isolated peripheral ulcerative keratitis (PUK) (3 eyes), scleritis (3 eyes), simultaneous PUK and scleritis (2 eyes) and periorbital mass (1 eye). CONCLUSION: Ophthalmological manifestations can be the initial findings in GPA. Since GPA can affect different structures of the eye, it sometimes might be challenging for ophthalmologists. Therefore, it is crucial for ophthalmologists to be well-informed about GPA-related ocular findings and to have a high index of suspicion for GPA. Although PUK associated with scleritis is highly suggestive for GPA, isolated cases of PUK or scleritis can be seen in GPA. Therefore, it is important to adopt a multidisciplinary approach, consider GPA in differential diagnosis, and benefit from accurate diagnostic tests.

Ocular lesions in patients with ulcerative colitis.

OBJECTIVE: Aim: To analyze the data and evaluate the prevalence of ocular lesions in patients with moderate ulcerative colitis. PATIENTS AND METHODS: Materials and Methods: We observed 112 patients aged 18-75 years old with clinically, endoscopically and histologically confirmed moderate ulcerative colitis which lasted at least 6 months. An ophthalmologic exam was performed to determine the presence of ocular symptoms. RESULTS: Results: Of the 112 patients with moderate ulcerative colitis, 21 (18,75%) had the following ocular lesions: episcleritis - 7 patients (6,25%), keratopathy - 5 patients (4,46%), uveitis - 5 patients (4,46%), cataract - 2 (1,78%) and scleritis - 2 (1.78%). CONCLUSION: Conclusions: Because ocular symptoms in patients with UC are often nonspecific, it may be beneficial to perform ophthalmologic examinations as a routine follow-up component of in such patients.

Autoimmune Inflammatory Eye Disease: Demystifying Clinical Presentations for the Internist.

PURPOSE OF REVIEW: Provide a framework for recognizing key symptoms and clinical findings in patients with autoimmune inflammatory eye disease. RECENT FINDINGS: The most common manifestations of autoimmune inflammatory eye disease are episcleritis, scleritis, uveitis (anterior, intermediate, posterior, and panuveitis), and keratoconjunctivitis sicca. Etiologies can be idiopathic or in association with a systemic autoimmune condition. Referral of patients who may have scleritis is critical for patients presenting with red eyes. Referral of patients who may have uveitis is critical for patients presenting often with floaters and vision complaints. Attention should also be directed to aspects of the history that might suggest a diagnosis of a systemic autoimmune condition, immunosuppression, drug-induced uveitis, or the possibility of a masquerade condition. Infectious etiologies should be ruled out in all cases. Patients with autoimmune inflammatory eye disease may present with ocular or systemic symptoms alone, or in combination. Collaboration with ophthalmologists and other relevant specialists is vital to optimal long-term medical care.

The eye is a common site of granulomatosis with polyangiitis. A collaborative study.

BACKGROUND: Ocular manifestations of granulomatosis with polyangiitis (GPA) have been reported in a limited number of studies and with largely variable frequency. Here we report on the clinical, diagnostic, and therapeutic features of a cohort of 63 GPA patients, with particular regard to 22 of them with ophthalmic involvement (35%). METHODS: Clinical manifestations, results of immunological findings, histopathological pictures, imaging data, Birmingham Vasculitis Activity Score, therapeutic regimens, and outcomes were retrospectively analyzed. At diagnosis, in addition to a structured clinical assessment, all patients underwent a comprehensive ophthalmologic examination. RESULTS: The most frequently involved organs were kidneys, lungs, ear/nose/throat, and eyes. Ocular manifestations were bilateral in 32%. The three most commonly diagnosed ophthalmologic manifestations were scleritis (36%), retro-orbital pseudotumor or orbital mass (23%), and episcleritis (13%). Ocular and systemic involvement were simultaneously present at onset in 41% of the patients; systemic involvement was followed by ocular lesions in 36%; ocular inflammation was followed by systemic manifestations in 18%; and an orbital mass in the absence of systemic disease characterized 5%. Glucocorticoids plus cyclophosphamide and glucocorticoids plus rituximab were the combined therapies most frequently employed during remission induction and remission maintenance, respectively. Persistent ophthalmologic and extra-ocular remissions were achieved in 77 and 64% of the patients, respectively. One to three systemic relapses were diagnosed in 7 patients (31.8%). At the last follow-up, a visual outcome 20/40 or better in 31 (70%) of 44 eyes was determined. CONCLUSIONS: The eye was involved in over one third of our patients with GPA. Increased awareness, early diagnosis, and multi-specialty collaboration are critical in achieving a favorable outcome of GPA.

[Ophthalmic manifestations of COVID-19]. / Oftal'mologicheskie proyavleniya COVID-19.

In March 2020 the World Health Organization (WHO) declared a pandemic of the novel coronavirus infection (COVID-19) caused by the SARS-CoV-2 respiratory virus. The high spread rate of the virus and the severity of the course of the disease are of great clinical and epidemiological significance, making it relevant for ophthalmologists to study the mechanisms of how SARS-CoV-2 infects ocular structures, as well as possible clinical manifestations of the infection in the organ of vision. This review contains analysis, systematization, and generalization of epidemiological and clinical data on SARS-CoV-2 ocular lesions and was carried out with the data found in scientific abstract databases. The article presents main clinical ophthalmic manifestations of COVID-19, lists the utilized schemes of etiotropic and symptomatic therapy, recommended preventive measures, and considers the possible ophthalmic complications after vaccination against COVID-19.

[New possibilities in therapy of ocular inflammation in rheumatic diseases]. / Novye vozmozhnosti terapii vospaleniya glaz pri revmaticheskikh zabolevaniyakh.

This review is devoted to the potential application of genetically engineered biological drugs of different classes in the treatment of main forms of uveitis and other types of non-infectious ocular inflammation in immunoinflammatory rheumatic diseases. The article presents the results of studies demonstrating the influence of interleukin-17 inhibitor secukinumab on the course of uveitis in spondylarthritis, shows the possibilities of treating uveitis in juvenile idiopathic arthritis with inhibitors of interleukin-6, co-stimulation of T-lymphocytes. Inhibition of interleukin-1 is considered an effective method of influencing the ocular inflammation in monogenic autoinflammatory syndromes and Behcet's disease. Rituximab is considered as an option for immunosuppressive therapy of non-infectious uveitis and scleritis.

Ocular manifestations of coronavirus disease 2019.

PURPOSE: Coronavirus disease 2019 (COVID-19) is an ongoing global public health problem, and most of the COVID-19 research is focused mainly on the respiratory system because of life-threatening results. However, manifestations in other organs should not be ignored since they can also be a mode of transmission. We sought to describe the ocular manifestations of COVID-19 and investigate the association between ocular involvement and clinical presentation and laboratory outcomes. METHODS: This cross-sectional study was conducted between March 1, 2020, and April 30, 2020. Ninety-three sequentially hospitalized and clinically confirmed COVID-19 patients were included in the study. The systemic and ocular symptoms, clinical findings, and laboratory outcomes were recorded. RESULTS: Of the 93 COVID-19 patients, 54 (58.1%) were male, and 39 (41.9%) were female. Mean age of the patients was 39.4 ± 21.9 (min 7, max 88) years. Twenty patients (n 21.5%) had at least one ocular abnormality. Most common findings included hyperemia (n = 20), epiphora (n = 9), increased secretion (n = 6), chemosis (n = 3), follicular conjunctivitis (n = 2), and episcleritis (n = 2). The most common symptom was photophobia (n 15). Patients with ocular involvement were more likely to have higher neutrophil counts (p = 0.001), and increased CRP (p < 0.001), PCT (p = 0.001), and ESR levels (p < 0.001). Mean lymphocyte count was statistically lower in patients with ocular manifestations (p = 0.001). Mean age and number of patients with fever over 37.3 °C in the ocular involvement group was found to be higher (p < 0.001, p = 0.006, respectively). CONCLUSION: Older age, high fever, increased neutrophil/lymphocyte ratio, and high levels of acute phase reactants seemed to be risk factors for ocular involvement.

Clinical and pathological findings in three dogs with a corneocentric presentation of nodular granulomatous episcleritis.

PURPOSE: To describe the clinical signs, management, histopathologic findings, and outcome of three dogs with a corneocentric presentation of nodular granulomatous episcleritis (NGE). METHODS: Three dogs of varying breeds were presented for a unilateral, nonpainful, and infiltrative corneal lesion in the dorsal aspect of the eye. Clinical response to symptomatic topical treatment directed at a presumed inflammatory or immune-mediated cause was poor. Due to this, and concerns of neoplasia, ultrasonography (n = 1), incisional biopsy (n = 2), and/or enucleation (n = 2) were performed. RESULTS: The inflammatory infiltrate observed on histopathology was identical to that seen in nodular granulomatous episcleritis in all three cases. However, atypically the inflammation was confined to the cornea and limbus, without episcleral or conjunctival involvement. Inflammation of the cornea was full thickness to Descemet's membrane. Following enucleation (n = 2), there were no postoperative complications, and no reported ophthalmic disease in the remaining eye. Currently, the single non-enucleated case remains controlled with systemic and topical immunosuppression. CONCLUSION: To the best of the authors' knowledge, this is the first report of an NGE condition purely affecting the full thickness of the cornea, without episcleral or conjunctival involvement. The authors propose this to represent an atypical corneocentric variant of NGE. This clinical presentation can resemble neoplasia; incisional biopsy is recommended for a definitive diagnosis. Further research into the optimal treatment strategies for this variant of NGE is required.

The Prevalence and Characteristics of Inflammatory Bowel Disease-related Ocular Involvement in Children.

BACKGROUND: Ocular manifestations (OMs) in patients with inflammatory bowel disease (IBD) are uncommon, particularly in children. We aimed to explore the prevalence and characteristics of IBD-associated OM in a large cohort study. METHODS: A cross-sectional study was performed using the Maccabi Healthcare Services (MHS) database. The eligible population included all patients diagnosed with IBD as children (<18 years) between January 2005 and July 2023. RESULTS: Out of 2567 children with IBD (males 55%, Crohn's disease 64%), 78 (3%) were diagnosed with OM at any time during the disease course. In 54 patients (69%), the ocular disease occurred after IBD diagnosis with a median time of 2.6 (0.47-7) years between the 2 events, whereas in 24 patients (31%), ocular involvement preceded IBD diagnosis with a median time of 2.1 (0.6-5.7) years. The presence of ocular involvement was associated with increased usage of systemic corticosteroids (P < .001) and biologic agents (P = .04). There were 55 patients with ocular involvement during childhood who were ever diagnosed with IBD. In this population, ocular involvement was also associated with increased usage of systemic corticosteroids (P < .001). The prevalence of OM among patients with IBD did not change significantly over time (P = .75), with a prevalence of 2.3% at the end of the study period. CONCLUSIONS: The prevalence of ocular involvement in children with IBD is rare and steady; it is also associated with a greater usage of systemic corticosteroids and biologic agents, potentially representing a more severe disease course.

The prevalence of ocular manifestations in children with inflammatory bowel diseases is 2.3%, steady over the years. Ocular manifestations were associated with systemic steroids and biologic agents treatment, potentially representing severe inflammatory bowel disease.

Multiple ocular manifestations in a patient diagnosed with herpes zoster ophthalmicus: case report.

Objective: Our purpose was to present a case of a patient diagnosed with herpes zoster ophthalmicus with multiple ocular manifestations. Case presentation: A 70-year-old Caucasian male presented to the hospital for headache and skin hyperesthesia on the scalp and forehead on the left side. The diagnoses of herpes zoster ophthalmicus and acute conjunctivitis were made for the left eye. The patient was followed up for 6 months and during that period the following diagnoses were made for the same eye: peripheral sterile corneal infiltrates, episcleritis, and hypertensive anterior uveitis. Discussions: Herpes zoster ophthalmicus occurs when the reactivation of the dormant virus involves the ophthalmic division of the trigeminal nerve. The most frequent ocular presentations are conjunctivitis, keratitis, uveitis, episcleritis, and scleritis. The standard therapy consists of antivirals, such as acyclovir, valacyclovir, and famciclovir to limit the replication of the virus. The patient's risk factors, the course of treatment, and the severity of the disease, all affect the prognosis, which is highly variable. Prevention of the disease consists of vaccination with one of the following two vaccines, Zostavax and Shingrix. Conclusions: Final visual acuity for the left eye remained 1 despite numerous manifestations of the disease. Abbreviations: VZV = Varicella-zoster virus, BCVA = best-corrected visual acuity, OU = both eyes, OD = right eye, OS = left eye, IOP = intraocular pressure, NCT = non-contact tonometer, ZVX = Zostavax vaccine.

Etanercept-associated episcleritis: a pediatric case report of a paradoxical adverse reaction and review of the literature.

Scleritis is an inflammation of the episcleral and scleral tissues, characterized by injection in both superficial and deep episcleral vessels. When only episcleral tissue is involved, it is referred to as episcleritis. Episcleritis is mainly idiopathic but may be secondary to an underlying rheumatologic disease. Despite being rare, drug-associated episcleritis and scleritis should also be included in the differential diagnosis. Tumor necrosis factor-alpha (TNF-α) inhibitors are generally well-tolerated, but etanercept, in particular, has the potential to cause paradoxical adverse reactions including ocular inflammations, such as uveitis, scleritis, and ocular myositis. Etanercept differs in its mechanism of action from other TNF-α inhibitors as it acts as a decoy receptor, and this may partly explain the more frequently reported etanercept-associated ocular inflammation. Etanercept may also be ineffective in preventing ocular inflammation. However, the dechallenge and rechallenge phenomena have proven there is a causative link between etanercept and new-onset ocular inflammation. We report a case of a 15-year-old boy with enthesitis-related arthritis and familial Mediterranean fever who presented with episcleritis and blepharitis while receiving etanercept treatment and subsequently showed dechallenge and rechallenge reactions. Therefore, physicians should also be aware that episcleritis should be considered a paradoxical adverse reaction to etanercept and can occur in pediatric patients. We also reviewed the English literature to provide an overview and evaluate intervention options.

Anterior Non-Necrotizing Scleritis with Active Uveitis in Cases of Ocular Syphilis.

PURPOSE: To study clinical characteristics and management outcomes of cases of ocular syphilis co-presenting with scleritis and active uveitis. METHODS: A retrospective analysis of cases diagnosed with ocular syphilis between January 2020 and December 2023 was conducted at a tertiary eye care centre. Clinical records, investigations, and outcomes were reviewed to identify cases with scleritis with active uveitis. Demographic data, clinical features, treatment modalities, and resolution patterns were analyzed. RESULTS: Among the 135 eyes of 95 cases of ocular syphilis studied, scleritis with uveitis was observed in 3.70% of eyes (five eyes). All cases with scleritis and uveitis were unilateral and male, with ages ranging from 32 to 61 years. Concurrent features included placoid chorioretinitis, retinal vasculitis, and anterior uveitis. Misdiagnosis with subsequent oral steroid therapy precipitated scleritis as an exacerbation in two cases. Three cases, which were previously undiagnosed, were found to be HIV-positive. Scleritis manifested as anterior, non-necrotizing inflammation, often accompanied by chemosis, and responded rapidly to antibiotic and non-steroidal anti-inflammatory therapy. Scleritis resolution preceded that of chorioretinitis and retinal vasculitis. CONCLUSIONS: Non-necrotizing anterior scleritis with chemosis can be a rare presentation of active syphilitic uveitis. Large placoid chorioretinitis lesions, preceding inadvertent oral steroid and/or undiagnosed HIV status were the possible risk factors for the development of concurrent scleritis.

Syphilitic scleritis and episcleritis: A review.

Scleritis and episcleritis are rare, but potentially sight-threatening forms of syphilis. To provide a full description of this neglected subset of ocular syphilis, we evaluated the English literature for reports of syphilitic scleritis and episcleritis, recording the demographics, clinical characteristics, serological data, management practices, treatment responses, and visual outcomes. Previously published descriptions of 44 patients with syphilitic scleritis (50 eyes) and 9 patients with syphilitic episcleritis (14 eyes) were identified. The predominant type of scleritis was anterior scleritis, accounting for 92.9% of cases, with nodular anterior scleritis being the most frequent subtype at 58.1%. Almost one-quarter of patients were co-infected with human immunodeficiency virus (HIV). Initial misdiagnosis was common and led to delays in initiating treatment with appropriate antibiotics. Visual outcomes were often good in both scleritis and episcleritis, irrespective of HIV infection status, although complications including scleral thinning, keratitis, and uveitis, along with permanent visual loss and an association with neurosyphilis, were reported. Response to antibiotic treatment was typically rapid, often within 1 week. With the rising global incidence of syphilis, testing patients with scleritis or episcleritis for this infectious disease is important to ensure prompt diagnosis and treatment for best ocular and systemic outcomes.

Ophthalmological Manifestations in Inflammatory Bowel Diseases: Keep an Eye on It.

BACKGROUND AND AIMS: Inflammatory bowel diseases (IBD) are multifactorial chronic inflammatory disorders affecting the gastrointestinal tract. However, a broad spectrum of extraintestinal manifestations (EIMs) is associated with IBD, affecting several organs and systems, such as the skin, musculoskeletal and hepatobiliary systems, and, not least, the eye. Approximately 10% of IBD patients can develop ocular EIMs (O-EIMs) with a higher prevalence in Crohn's disease (CD). Eye-redness, photophobia, pain, and blurred vision are the common symptoms, with a wide rate of severity and clinical impact on the quality of life. This narrative review aims to summarize the prevalence, pathogenesis, and current evidence-based management of O-EIMs, underlying the importance of a holistic approach and specialties collaboration for a prompt diagnosis and treatment. METHODS: PubMed was searched up to December 2023 to identify relevant studies investigating the pathogenesis, epidemiology, and treatment of O-EIMs in IBD patients. RESULTS: The mechanisms underlying O-EIMs are partially unknown, encompassing immune dysregulation, shared antigens between the eye and the gut, genetic predisposition, and systemic inflammation driven by high levels of interleukins and cytokines in IBD patients. The complexity of O-EIMs' pathogenesis reflects in the management of these conditions, varying from topical and systemic steroids to immunomodulatory molecules and biologic therapy, such as anti-tumor necrosis factor (TNF)-alpha. A multidisciplinary approach is the backbone of the management of O-EIMs.

Mimickers of anterior uveitis, scleritis and misdiagnoses- tips and tricks for the cornea specialist.

BACKGROUND: Anterior uveitis, inflammation of the anterior chamber and related structures, is a cohort of diseases that can present to almost any general or sub-specialty Ophthalmology practice. Its features classically involve anterior chamber cell and flare. Below the surface of these two signs exist a panoply of diagnoses. BODY: The purpose of this review is to provide a general framework for diagnoses of anterior uveitis that are often missed as well as non-uveitic pathologies that often mimic anterior uveitis. Diagnostic deviation in either direction can have vision-threatening and rarely life-threatening consequences for patients. Using a comprehensive literature review we have collected a broad spectrum of etiologies of anterior uveitis that are easily missed and non-uveitic pathologies that can masquerade as anterior uveitis. CONCLUSIONS: We present a focused review on specific misdiagnosed anterior uveitis pathologies and some of the conditions that can masquerade as anterior uveitis and scleritis.

COVID-19 and Its Ophthalmic Manifestations: A Literature Review.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus discovered in late 2019 in Wuhan, Hubei Province, China. The virus has now developed into a full-scale global pandemic affecting hundreds of millions of people to date. A majority of cases present with nonspecific acute upper respiratory symptoms. A wide range of systemic symptoms has been reported, with some patients presenting with nonspecific extrapulmonary symptoms. Recently, there has been an increased association of COVID-19-positive patients presenting with ocular symptoms. As an increasing number of patients present with ophthalmic manifestations, recognizing these visual symptoms is of utmost importance. Some patients may present with ocular symptoms as the first indication of COVID-19 infection; quickly isolating and starting treatment can aid in stopping the spread of this novel coronavirus. This review will describe the current epidemiology and pathophysiology of SARS-CoV-2, emphasizing the ophthalmic manifestations and their clinical course progression. Further, we will be reporting on the growing number of rare ocular manifestations that have occurred in some COVID-19-positive patients, along with the route of transmission, specific manifestations, and the treatment methods for both these pulmonary and extrapulmonary symptoms, specifically the ocular manifestations.

Treatment of Steroid-Resistant Nodular Episcleritis With Tacrolimus: A Case Report.

A 46-year-old male, with no chronic medical illness, complained of pain, tearing, and redness for one-month duration, with no photophobia, discharge, or decrease in visual acuity. Examination revealed a small, painful, red swelling in the left sclera. Slit-lamp examination using a narrow bright slit beam revealed edema of the episcleral layer and injection of the superficial episcleral blood vessels. The rest of the anterior segment exam and fundoscopy were normal. The laboratory investigations and systemic workup were normal. The patient was initially treated with prednisolone acetate (Pred Forte) 1% every three hours per day for one week, and then four times per day for another week, and tapered gradually over eight weeks with systemic nonsteroidal anti-inflammatory drugs (NSAIDs) as diclofenac sodium for eight weeks with mild improvement of clinical symptoms, but the size of the lesion remained without any change and the patient started to have a relapse of symptoms at the end of the course. Topical tacrolimus drops of 0.1% concentration were prepared in the pharmacy under complete sterile precautions and were used four times per day for the following six weeks duration instead of the initial therapy (steroids and NSAIDs). Tacrolimus drops were then tapered gradually over another six weeks duration. The patient showed dramatic suppression of inflammation and exceptional remission of symptoms with complete resolution of the episcleritis. Topical tacrolimus is very effective in the treatment of nodular episcleritis, which is resistant to steroid therapy. Patients with nodular episcleritis suffer from prolonged bouts of inflammation that are characteristically more painful than the diffuse type and may be associated with other systemic diseases. The case is steroid-resistant nodular episcleritis, which did not respond to the usual treatment and showed a good response to treatment with tacrolimus, which was first introduced in episcleritis. Tacrolimus is being used in other ocular diseases, but its use in episcleritis is unique.

Episcleritis; and posterior uveitis misdiagnosed as orbital cellulitis in a child patient with Behçet's disease.

Behçet's disease is a chronic multisystem vasculitis that presented with several manifestations. Episcleritis is a benign inflammation of the episcleral tissue and is rarely reported in Behçet's disease. We reported an 11-year-old girl who was admitted due to pain and swelling around the left eye with initial diagnosis of preseptal cellulitis. The patient had a history of recurrent oral aphthous ulcers and genital ulcers. Episcleritis and posterior uveitis were reported in ophthalmic examination and ultrasonography. Pathergy skin test and human leukocyte antigens (HLA) B5 and HLA-B51 were positive, consistent with the diagnosis of Behcet's disease. This case report emphasizes that various pathological causes may cause episcleritis and uveitis in children, one of which is rheumatic diseases, that should always be considered.