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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 218-224

Evidence-based Homoeopathy: A case report of nodular episcleritis


Department of Homoeopathy, Sathye Eye Research Institute for Alternative Medicines, Pune, Maharashtra, India

Date of Submission11-Jan-2020
Date of Acceptance28-Jul-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Sandeep Sudhakar Sathye
Plot No. 4, S. No. 28/4A, Sadanand Nagar, Anand Nagar, Hingne (Khurd), Sinhagad Road, Pune - 411 051, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrh.ijrh_101_19

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  Abstract 


Introduction: Nodular episcleritis (NE) is a variety of episcleritis characterised by inflammation of subconjunctival connective tissue leading to development of a localised raised congested nodule with mild pain and tenderness. It can last for weeks with a tendency to recur and is often considered as an allergic reaction to endogenous toxins. Conventional treatment includes the use of topical steroids and non-steroidal anti-inflammatory drugs which give a temporary relief. Case Summary: The case of a 62-year-old male patient suffering from NE in the right eye for 15 days not responding to conventional treatment is reported here. Homoeopathic Mercurius solubilis 30C prescribed on the basis of totality of symptoms resolved NE within a week with no recurrence for 1 year and 4 months. This case report with photographic evidence shows the effectiveness of Mercurius solubilis 30C in non-rheumatoid nodular episcleritis.

Keywords: Eye, Homoeopathy, Inflammation, Mercurius solubilis, Modified Naranjo criteria, Nodular episcleritis


How to cite this article:
Sathye SS. Evidence-based Homoeopathy: A case report of nodular episcleritis. Indian J Res Homoeopathy 2020;14:218-24

How to cite this URL:
Sathye SS. Evidence-based Homoeopathy: A case report of nodular episcleritis. Indian J Res Homoeopathy [serial online] 2020 [cited 2020 Oct 29];14:218-24. Available from: https://www.ijrh.org/text.asp?2020/14/3/218/296241




  Introduction Top


Episcleritis is an acute, mostly unilateral inflammatory condition involving deep subconjunctival connective tissue and is common in adults and in females.[1] Most cases of episcleritis are idiopathic, but a few are associated with connective tissue diseases.[2] However, it is often regarded as an allergic reaction to an endogenous toxin.[3] Clinically, episcleritis is associated with ocular congestion, mild pain and tenderness. The course of episcleritis is long, usually lasting for weeks with a tendency to recur.[4] Resolution takes a longer time in elderly patients.[5] Watson and Hayreh classified episcleritis into simple and nodular variety.[6] Simple (diffuse) variety is common, affecting any sector of the eye and usually resolves spontaneously within 1–2 weeks,[7] whereas nodular episcleritis (NE) is relatively less common and characterised by development of a localised, raised congested nodule. It involves one sector of the eye usually temporal, with little or no pain but tenderness.[3] It lasts longer than the simple variety, and spontaneous resolution occurs in 5–6 weeks.[8] However, it has a strong tendency to recur.[3] In cases of episcleritis, investigations are not usually required unless there is persistent inflammation or a history suggestive of systemic disease.[8] Conventional treatment for NE includes the use of topical steroids and non-steroidal anti-inflammatory drugs, but they give temporary relief and are associated with complications if steroids are used for long duration.[3] Symptomatic relief can be achieved with the use of hot compresses.

Homoeopathic literature has mentioned different medicines for episcleritis, and these are as follows, with their gradation:

  • Eye – Inflammation – Episclera and sclera – Acon., Aur., Cinnb., Cocc., Kalm., Merc., Nux-m., Puls., Sep., Spig., Sulph., Ter. Thuja[9]
  • Episcleritis and Scleritis – Kalm., Merc., Sep., Thu., Aco., Aur., Cinnab., Coccul., Nux. m., Puls., Spig., Tereb. and Sulph[10]
  • Eye – Sclerotica – Inflammation – Superficial (episcleritis) – Acon., Bell., Bry., Kali-i., Merc-c., Rhus-t., Ter. and Thuj[11]
  • Eye – Sclerotica – Episcleritis – Merc., Nux-m. and Thuj[12]
  • Eye – Inflammation – Sclerotic: Aco., Ars., Aur., Bar-c., Bell., Bry., Hep., Kali-i., Kalm., Merc., Plb., Rhus-t., Sep., Spi., Tereb. and Thu[13]
  • Eye – Inflammation – Sclerotic: Aco., Cocc., Kalm., Merc., Psor., Rhus-t., Spig. and Thuj.[14]



  Case Report Top


Patient history

A male patient aged 62 years reported on 12 July 2018 to Sathye Eye Research Institute for Alternative Medicines, Pune, India, Outpatient Department with complaints of redness, swelling and occasional foreign body sensation in the right eye for the last 15 days. He was previously evaluated by an ophthalmologist as NE and treated with topical anti-inflammatory drugs without much relief. So the patient approached for homoeopathic treatment. The patient was also a known case of hypertension and diabetes mellitus, controlled with conventional treatment. He had no associated complaints of joints or fever or weight loss, etc. There was no past history of similar ocular complaint, ocular trauma or surgery, general illness, etc.

Clinical examination

On general examination, there was no fever or lymphadenopathy. Systemic examination, including respiratory and musculoskeletal system, was reported normal. Oral examination revealed no dental caries. On eye examination, the patient's vision was 6/6 on Snellen chart in both eyes with hypermetropic glasses. On slit-lamp examination, there was congestion on the temporal side with a localised raised area of about 4–5 mm from the limbus in the right eye [Figure 1] and [Figure 2]. There was mild localised tenderness, and conjunctiva was moving freely over the nodule. There was no abnormality either on cornea, iris or lens.
Figure 1: Nodular episcleritis before treatment (dated: 12 July 2018)

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Figure 2: Magnified view of nodular episcleritis before treatment

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Case analysis

In this case, local signs and symptoms were considered for repertorisation such as inflammation of the sclera and episcleral tissue, affection of the right eyeball, localised pain on pressure and foreign body sensation in the eye. Repertorisation was done with the help of homoeopathic software, Hompath Vital® (Mind Technologies Pvt. Ltd.; Mumbai, India: 2000), and repertorisation chart is presented in [Figure 3].
Figure 3: Repertorisation chart

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The first six medicines with higher score are as follows in their descending order: Belladonna, Mercurius solubilis (Merc)., Aconite, Thuja, Rhus toxicodendron. and Bryonia.

In Belladonna, inflammation is severe in intensity with throbbing pain, heat and dry sensation in the eye. Aconite is useful in acute stage when there are violent, burning and shooting pains with dryness and sensitiveness of the eyeball to touch. Thuja has an affinity for the left eyeball, while Rhus-t and Bryonia are indicated in rheumatic inflammation. Knerr [12] has mentioned Merc, Nux moschata and Thuja as the chief medicines for episcleritis, but Nux-m is indicated in NE if the nodule is very large and painful, and the patient is drowsy with sleepy expression of the eyes,[4] so these medicines were eliminated. Hence, Mercurius solubilis was selected for this case, and Knerr has also mentioned it for episcleritis if there is a scleral congestion, especially between insertion of recti muscle where the sclera is slightly bulged and thinner.[12]

Intervention

Homoeopathic Mercurius solubilis 30C-medicated globules of size no. 35 were dispensed with a dose of two pills, to be taken four times a day for 2 days; on the basis of totality of local signs and symptoms. The patient was not advised any local treatment or any alteration in their diet and regimen.

Follow-up and outcome

On 14 July 2018, there was a mild reduction of redness and foreign body-like sensation in the eye. On eye examination, a reduction of congestion, tenderness and size of nodule was observed. Hence, the same medicine was continued in BD dose for 4 days.

On 19 July 2018, there was a further reduction of redness of the eye with no foreign body sensation. On eye examination, congestion was much reduced with no tenderness and nodule has resolved completely, so medicine was stopped [Figure 4] and [Figure 5].
Figure 4: Nodular episcleritis resolved after treatment (dated: 19 July 2018)

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Figure 5: Magnified view of resolved nodular episcleritis after treatment

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On 1 October 2018, the patient was contacted on phone and he reported that there were no ocular complaints thereafter, so did not come for follow-up.

On 7 December 2019, he came for check-up after telephonic contact and reported no recurrence of eye complaints. Eye examination showed no abnormal findings, especially related to the sclera. The timeline of the patient including first and follow-up visits is mentioned in [Table 1].
Table 1: Timeline of the patient including first and follow-up visits

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The modified Naranjo criteria were used in this case for assessing causal attribution to the medicine prescribed,[15] and the total score was 9 [Table 2]. It suggests a 'definite' association between the medicine prescribed and the final outcome (definite: ≥9, probable 5–8, possible 1–4 and doubtful ≤0).[16]
Table 2: Assessment of outcome with modified Naranjo criteria

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  Discussion Top


NE is considered to be associated with rheumatic conditions and foci of infection principally in teeth and tonsils.[17] In the case presented here, there were no rheumatic or other complaints related to systemic diseases, however, perhaps was a known diabetic, and since dialetics are prone to infection, so the probable cause of NE could be a low-grade endogenous infection. Materia Medica books mention the use of Mercurius solubilis for suppurative processes in the body, and medicine has probably acted on endogenous septic focus leading to a rapid resolution of NE in this case.

Mercurius solubilis was used in medium (30C) potency because the patient was of old age and on allopathic treatment for diabetes and hypertension, and NE had a moderate intensity of symptoms, which showed a moderate susceptibility of the patient. Similarly, pathology was reversible in nature, and prescription was based on local, rather than on general symptoms of the patient. NE has resolved within a week with no untoward effects and without recurrence. This justifies the correct selection of remedy, its potency and repetition.

There is a least possibility of natural resolution of NE in this case, as it usually lasts for weeks with a strong tendency to recur; similarly, the duration of inflammation is more in non-rheumatoid NE patients [1] and in aged patients.[5] Thus, NE is not a benign and self-limiting variety of episcleritis but an allergic reaction to endogenous toxin, so unless treated with systemic medication, it is bound to recur again and again. In the case reported, the patient was of old age group and suffering from non-rheumatoid NE. After starting homoeopathic treatment, there was a reduction of all ocular complaints along with size of nodule within 2 days and with a complete resolution of NE within the next 5 days. As patient's complaints were not severe, no supportive treatment was given. No alteration in diet/regimen was suggested, and no recurrence was reported in for the last 1 year and 4 months. After assessing the case with modified Naranjo criteria, a 'definite' association between the medicine and the outcome was found. Thus, all the above points go in favour of medicinal effect in resolution of NE.

Modern literature states that most cases of episcleritis are idiopathic. Investigations are not usually required unless there is persistent inflammation or a history suggestive of systemic disease.[8] In the case reported, it was the first episode of episcleritis, and there were no obvious signs or symptoms of systemic disease, especially related to the respiratory tract, skin, joints or abdomen, so detailed investigations were not done before or during homoeopathic treatment.

NE is a less common condition, and it was treated successfully with a single systemic homoeopathic medicine within a week. Such case with photographic documentary evidence was not published so far in Homoeopathy as per internet search, so this case was considered for presentation.

Limitation of this study was less number of total follow-ups (i.e. 3), but as the patient had no ocular complaints after receiving homoeopathic treatment, he did not come for regular follow-up.


  Conclusion Top


This case presentation with ocular photographic evidence shows effectiveness of homoeopathic Mercurius solubilis 30C in NE of non-rheumatoid origin, however, a case series or controlled clinical trials with detailed investigations are required to validate the results.

Declaration of patient consent

The author declares that he has obtained a written informed consent from the patient. In the form, the patient has given written consent for his clinical information and images to be reported in the journal. The patient understands that his name will not be published and due efforts will be made to conceal his identity.

Financial support and sponsorship

Nil.

Conflicts of interest

None declared.



 
  References Top

1.
McGavin DD, Williamson J, Forrester JV, Foulds WS, Buchanan WW, Dick WC, et al. Episcleritis and scleritis. A study of their clinical manifestations and association with rheumatoid arthritis. Br J Ophthalmol 1976;60:192-226.  Back to cited text no. 1
    
2.
Salama A, Elsheikh A, Alweis R. Is this a worrisome red eye? Episcleritis in the primary care setting. J Community Hosp Intern Med Perspect 2018;8:46-48.  Back to cited text no. 2
    
3.
Sihota R, Tandon R, editors. Parsons' Diseases of the Eye. 20th ed. New Delhi: Elsevier; 1984. p. 210-11.  Back to cited text no. 3
    
4.
Norton AB. Ophthalmic Diseases and Therapeutics. 3rd ed. New Delhi: B. Jain Publishers (P) Ltd.; 1987. p. 277-82.  Back to cited text no. 4
    
5.
Lyle TK, Cross AG. May and Worth's Manual of Diseases of the Eye. 12th ed. London: Bailliere, Tindall and Cox.; 1959. p. 212-6.  Back to cited text no. 5
    
6.
Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol 1976;60:163-91.  Back to cited text no. 6
    
7.
Kanski JJ. Clinical Ophthalmology: A Systematic Approach. 5th ed. Edinburgh: Butterworth Heinemann, Elsevier science.; 2003. p. 154-5.  Back to cited text no. 7
    
8.
Tsai JC, Denniston AK, Murray PI, Huang JJ, editors. Oxford American Handbook of Ophthalmology. Oxford, UK: Oxford University Press; 2011. p. 220.  Back to cited text no. 8
    
9.
Schroyens F. Synthesis, Repertorium Homeopathicum Syntheticum. 8.1 ed. London: Homoeopathic Book Publishers; 2001. p. 437.  Back to cited text no. 9
    
10.
Moffat JL. Homoeopathic Therapeutics in Ophthalmology. New Delhi: B. Jain Publishers (P) Ltd.; 1995. p. 129.  Back to cited text no. 10
    
11.
Boericke W. Boericke's New Manual of Homoeopathic Materia Medica with Repertory. 3rd Revised and Augmented ed. New Delhi: B. Jain Publishers (P) Ltd.; 2007. p. 383-6, 646.  Back to cited text no. 11
    
12.
Knerr CB. Repertory of Hering's Guiding Symptoms of our Materia Medica. Reprinted. New Delhi: Jain Publishing Co.; 1982. p. 322.  Back to cited text no. 12
    
13.
Boger CM. Boenninghausen's Characteristic and Repertory. New Delhi: B. Jain Publishers (P) Ltd; 1987. p. 309-13.  Back to cited text no. 13
    
14.
Kent JT. Repertory of Homoeopathic Materia Medica. New Delhi: B. Jain Publishers (P) Ltd.; 1989. p. 244.  Back to cited text no. 14
    
15.
Rutten L. Prognostic factor research in Homoeopathy. Indian J Res Homoeopathy 2016;10:59-65.  Back to cited text no. 15
  [Full text]  
16.
Van Haselen RA. Homoeopathic clinical case reports : Development of a supplement (HOM-CASE) to the care clinical case reporting guideline. Complement Ther Med. 2016;25:78-85.  Back to cited text no. 16
    
17.
Tassman IS. The Eye Manifestations of Internal Diseases (Medical Ophthalmology). 3rd ed. St. Louis: CV Mosby Co.; 1951. p. 137.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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