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Atypical Conjunctival Lesion Associated With a Bladder Problem

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A white man in his 70s was referred for evaluation of a rapidly enlarging fleshy nodule of the right nasal conjunctiva. The patient noted redness, pain, and a foreign body sensation on his right eye for 2 weeks. The general ophthalmologist prescribed a 3-week course of oral prednisone, 20 mg/d, that reduced surrounding inflammation and pain, but the lesion did not change in appearance. The chest radiographic findings and blood work results were unremarkable. The lack of response to oral prednisone therapy led to suspicion of a possible malignant neoplasm, and the patient was referred for our opinion.

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Nodular episcleritis unresponsive to corticosteroids

B. Perform a complete excisional biopsy of the lesion

The differential diagnosis of a rapidly growing amelanotic conjunctival and episcleral nodule includes various benign and malignant lesions. A rapidly enlarging mass raises concern for a malignant process, and evaluation by an ocular oncologist can be considered. Nodular episcleritis is typically responsive to anti-inflammatory agents.1 However, recurrence or failure to completely respond to treatment requires further workup. Although episcleritis is usually idiopathic, up to one-third of patients have an associated systemic disorder, including collagen-vascular, inflammatory bowel, and dermatologic disorders; metabolic diseases; medication toxic effects; and hematolymphoid malignant neoplasms.1,2 This patient’s history of CLL/SLL and lack of response to oral prednisone therapy raised concern for possible conjunctival involvement by CLL/SLL. Although excisional biopsy is not typically performed for nodular episcleritis, it was necessary to rule out malignancy (choice B). Intralesional corticosteroid injection (choice A) is not recommended because of the patient’s poor response to prior corticosteroid treatment. Topical antibiotics (choice C) should not be administered until the etiology of the mass is determined. Obtaining a magnetic resonance image of the brain and orbits (choice D) would be an appropriate step if the lesion was determined to be lymphoma.

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Article Information

Corresponding Author: Carol L. Shields, MD, Ocular Oncology Service, Wills Eye Hospital, 840 Walnut St, Ste 1440, Philadelphia, PA 19107 (carolshields@gmail.com).

Published Online: December 19, 2019. doi:10.1001/jamaophthalmol.2019.4596

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported in part by the Eye Tumor Research Foundation (Dr Shields).

Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study, in the collection, analysis and interpretation of the data, and in the preparation, review or approval of the manuscript.

Additional Contributions: We thank the patient for granting permission to publish this information. Sara Lally, MD, Ocular Oncology Service, Wills Eye Hospital, contributed to diagnosis, management, and overall supervision of patient care. Antonio Yaghy, MD, Ocular Oncology Service, Wills Eye Hospital, contributed to the article’s written composition. Neither was financially compensated for these contributions.

References
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Kesen  MR, Edward  DP, Rao  NA, Sugar  J, Tessler  HH, Goldstein  DA.  Atypical infectious nodular scleritis.  Arch Ophthalmol. 2009;127(8):1079-1080. doi:10.1001/archophthalmol.2009.197PubMedGoogle ScholarCrossref
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