What do candle wax drippings look like on fundus examination?

Yellow-white globular infiltrates along peripheral retinal veins Also called taches de bougie, they are yellow-white globular perivenous infiltrates, usually peripheral, resembling wax that has run down a candle and hardened.

Fine crystalline deposits scattered through the macula

Flat grey patches at the level of the pigment epithelium

Sharply defined pale wedges along the arterioles

What is the material that forms candle wax drippings?

A perivascular cuff of inflammatory cells and exudate The cuff of inflammatory cells and exudate around inflamed veins is granulomatous in sarcoid, and because the cuffing is patchy rather than continuous it looks knobby and irregular.

Lipid released from damaged photoreceptors

Calcium deposited within the vessel wall

Proliferated pigment epithelial cells along the vein

In which condition are candle wax drippings most typically seen?

Sarcoidosis Sarcoidosis is the most typical setting, although tuberculosis and other granulomatous infections, multiple sclerosis-associated intermediate uveitis, pars planitis, Behcet disease and Eales disease can also produce periphlebitis.

Central serous chorioretinopathy

How does the periphlebitis of Behcet disease tend to differ from that of sarcoidosis?

It tends to be occlusive and more severe In Behcet disease the periphlebitis tends to be occlusive and more severe than the patchy granulomatous cuffing seen in sarcoid.

It never involves the peripheral retina

It resolves without any treatment

What does a quiet anterior chamber mean in a patient with suspected sarcoid periphlebitis?

It does not exclude the diagnosis Sarcoid periphlebitis can occur with little or no anterior chamber inflammation, so a quiet front of the eye does not exclude it.

It confirms the inflammation is purely infectious

It indicates that treatment can safely be stopped

It rules out any posterior segment inflammation

Which features indicate that perivenous sheathing is active rather than an old scar?

Fluffy yellow-white sheathing with leakage on angiography Active periphlebitis is fluffy and yellow-white with angiographic leakage and vitreous cells, whereas inactive sheathing is thin, white and non-leaking, and being a scar needs no treatment.

Thin, white, sharply demarcated sheathing without leakage

Narrowed vessel sleeves with a clear vitreous

Pigmented lines following the vein with window defects

Which chest investigation is preferred when sarcoid periphlebitis is suspected?

High-resolution CT of the chest High-resolution CT is preferred because chest radiographs miss many cases; serum angiotensin-converting enzyme and lysozyme are supportive but neither sensitive nor specific.

Chest radiograph alone, which is sufficient

No imaging unless the patient is breathless

Which test should be done before starting steroid or immunosuppressive treatment for periphlebitis?

Testing for tuberculosis Tuberculosis testing is required before steroid or immunosuppressive treatment, since granulomatous infection can produce the same perivenous appearance.

How is periphlebitis without macular oedema or vitritis managed?

Observation, with no treatment needed Periphlebitis without macular oedema or vitritis may need nothing beyond observation; stepwise treatment is reserved for significant inflammation or macular oedema.

Immediate oral corticosteroids with a taper

Scatter laser to the peripheral retina

Intravitreal anti-VEGF injection

What should long-term follow-up of sarcoid periphlebitis watch for?

Raised intraocular pressure, cataract and recurrent macular oedema Sarcoid can relapse years later, so long-term follow-up attends to intraocular pressure, cataract and recurrent macular oedema, with a physician involved for the systemic disease.

Progressive axial elongation of the globe

Candle Wax Drippings: Sarcoid Retinal Periphlebitis

Candle wax drippings, or taches de bougie, are one of the more recognizable retinal findings in ocular sarcoidosis.

Along the retinal veins, usually in the periphery, you see yellow-white, globular, perivenous infiltrates that look like wax that has run down the side of a candle and hardened.

What causes the appearance

The material is a perivascular cuff of inflammatory cells and exudate that accumulates around inflamed veins.

In sarcoid it is granulomatous, and the cuffing is patchy, not continuous, which gives the knobby, irregular outline.

Small hemorrhages, vascular leakage, and occasionally neovascularization can follow.

When you will see it

Sarcoidosis is the most typical setting (see ocular sarcoidosis and sarcoid uveitis)
Tuberculosis and other granulomatous infections
Multiple sclerosis-associated intermediate uveitis, where periphlebitis is a feature
Pars planitis, often with snowbanking and snowballs in the vitreous (see pars planitis)
Behçet disease, in which periphlebitis tends to be occlusive and more severe
Eales disease and other peripheral retinal vasculopathies

The periphlebitis of sarcoid can occur with little or no anterior chamber inflammation, so a quiet front of the eye does not exclude it.

Test your knowledge 10 questions from this article

Related findings that support sarcoid

Mutton-fat keratic precipitates and iris nodules (see keratic precipitates)
“String-of-pearls” vitreous opacities
Optic disc granuloma or swelling
Choroidal granulomas and, in some cases, macular edema
Bilateral hilar lymphadenopathy on chest imaging

Investigation

Chest imaging, ideally a high-resolution CT, since chest radiographs miss many cases
Serum angiotensin-converting enzyme and lysozyme, which are supportive but neither sensitive nor specific
Tuberculosis testing before steroid or immunosuppressive treatment
Fluorescein angiography to show leakage along the veins, capillary non-perfusion, and macular edema
Biopsy of accessible lesions, when the diagnosis is uncertain

Treatment

Periphlebitis without macular edema or vitritis may need no treatment beyond observation.

When there is significant inflammation or macular edema, treatment typically follows a stepwise path.

Periocular or intravitreal corticosteroid injection for unilateral disease
Oral corticosteroids for bilateral or severe disease, with a taper plan
Steroid-sparing agents such as methotrexate or mycophenolate when long-term control is needed
Adalimumab in refractory cases
Laser or anti-VEGF for retinal neovascularization after ischemia is documented

Looking for it in practice

The sheathing tends to start in the peripheral retina, so the finding is easily missed without indirect ophthalmoscopy and scleral depression.

Many patients are seen with vague floaters and blurred vision, and a dilated exam with a wide field of view is the only way to find it.

Wide-field fluorescein angiography is helpful because it shows vascular leakage and capillary dropout that are invisible on clinical examination, and it can show how much of the disease is active when the clinical picture is mixed.

A practical point is that sheathing should be differentiated from the inactive, white, narrowed vessel sleeves of old inflammation.

Active periphlebitis is fluffy and yellow, and it is associated with leakage on angiography.

Inactive sheathing is thin, white, and without leakage.

That distinction decides whether treatment needs to be escalated, since inactive sheathing is a scar and does not need treatment (see retinal vasculitis sheathing patterns).

Clinical eye photograph illustrating Candle Wax Drippings Sarcoid Periphlebitis

Distinguishing active periphlebitis from old sheathing

Active periphlebitis is fluffy, yellow-white, and associated with leakage on fluorescein angiography and with cells in the vitreous. Old sheathing is thin, white, and sharply demarcated, without leakage or vitritis. The distinction matters because inactive sheathing is a scar and needs no treatment, while active periphlebitis can lead to occlusion, ischemia, and neovascularization.

Following the patient

Wide-field fluorescein angiography helps to document leakage and nonperfusion in the periphery, and it can guide laser to ischemic retina if neovascularization develops. Follow the patient with serial examinations and imaging while treatment is tapered. Because sarcoidosis is a systemic disease, coordinate with a physician for chest imaging, pulmonary function, and monitoring of the effects of long-term immunosuppression.

Pitfalls

Do not exclude sarcoid because the front of the eye is quiet
Do not rely on a normal chest radiograph, since high-resolution CT is more sensitive
Do not start steroids before tuberculosis and syphilis have been considered
Do not forget that periphlebitis may be the first sign of multiple sclerosis in a young adult

What to tell the patient

Explain that the retinal changes reflect inflammation of the vessel walls, that treatment is aimed at calming it, and that regular examinations are needed because the disease can come back. Encourage them to report new floaters, blurred vision, or pain.

Prognosis

Many patients do well, but sarcoid can relapse years later.

Long-term follow-up with attention to intraocular pressure, cataract, and recurrent macular edema is important.

Patients should also know that sarcoidosis is a systemic disease, and that a pulmonologist or rheumatologist should be involved in the care, because the eye may be the only organ showing symptoms at the time of diagnosis.

References

Herbort CP, Rao NA, Mochizuki M. International criteria for the diagnosis of ocular sarcoidosis: results of the first International Workshop on Ocular Sarcoidosis. Ocul Immunol Inflamm. 2009;17:160-169.
Jabs DA, Johns CJ. Ocular involvement in chronic sarcoidosis. Am J Ophthalmol. 1986;102:297-301.
Pasadhika S, Rosenbaum JT. Ocular sarcoidosis. Clin Chest Med. 2015;36:669-683.
Dana MR, Merayo-Lloves J, Schaumberg DA, Foster CS. Prognosticators for visual outcome in sarcoid uveitis. Ophthalmology. 1996;103:1846-1853.

Test yourself

A few questions straight from this article.

1 / 10 0 correct

What do candle wax drippings look like on fundus examination?
Also called taches de bougie, they are yellow-white globular perivenous infiltrates, usually peripheral, resembling wax that has run down a candle and hardened.
What is the material that forms candle wax drippings?
The cuff of inflammatory cells and exudate around inflamed veins is granulomatous in sarcoid, and because the cuffing is patchy rather than continuous it looks knobby and irregular.
In which condition are candle wax drippings most typically seen?
Sarcoidosis is the most typical setting, although tuberculosis and other granulomatous infections, multiple sclerosis-associated intermediate uveitis, pars planitis, Behcet disease and Eales disease can also produce periphlebitis.
How does the periphlebitis of Behcet disease tend to differ from that of sarcoidosis?
In Behcet disease the periphlebitis tends to be occlusive and more severe than the patchy granulomatous cuffing seen in sarcoid.
What does a quiet anterior chamber mean in a patient with suspected sarcoid periphlebitis?
Sarcoid periphlebitis can occur with little or no anterior chamber inflammation, so a quiet front of the eye does not exclude it.
Which features indicate that perivenous sheathing is active rather than an old scar?
Active periphlebitis is fluffy and yellow-white with angiographic leakage and vitreous cells, whereas inactive sheathing is thin, white and non-leaking, and being a scar needs no treatment.
Which chest investigation is preferred when sarcoid periphlebitis is suspected?
High-resolution CT is preferred because chest radiographs miss many cases; serum angiotensin-converting enzyme and lysozyme are supportive but neither sensitive nor specific.
Which test should be done before starting steroid or immunosuppressive treatment for periphlebitis?
Tuberculosis testing is required before steroid or immunosuppressive treatment, since granulomatous infection can produce the same perivenous appearance.
How is periphlebitis without macular oedema or vitritis managed?
Periphlebitis without macular oedema or vitritis may need nothing beyond observation; stepwise treatment is reserved for significant inflammation or macular oedema.
What should long-term follow-up of sarcoid periphlebitis watch for?
Sarcoid can relapse years later, so long-term follow-up attends to intraocular pressure, cataract and recurrent macular oedema, with a physician involved for the systemic disease.

Ahmed Ophthalmologist

Writes and reviews the clinical articles on Educate. Every post is checked against peer-reviewed sources before it goes live.

Candle Wax Drippings: Periphlebitis in Sarcoid Uveitis and What the Sheathing Looks Like