Practice Essentials
Episcleritis is an acute inflammation of the episclera that can affect one or both eyes. [1] Although it frequently is of unknown cause, around 26% to 36% of cases can be linked to underlying systemic conditions such as rheumatoid arthritis, ulcerative colitis, psoriatic arthritis, or systemic lupus erythematosus. Less commonly, infections such as Lyme disease and syphilis may also be associated with episcleritis. [2]
Episcleritis is self-limited and the prognosis is good. [3]
Patients may experience redness and mild ocular discomfort or pain; visual acuity is normal. Discharge and photophobia are rare. [2]
The two clinical types of episcleritis are diffuse and nodular or focal (nodular/focal). Patients with diffuse episcleritis, the more common type, experience intermittent episodes of moderate-to-severe inflammation that recur as often as every 1 to 3 months.
Patients with nodular/focal episcleritis have longer, more painful episodes, and they often have an associated systemic disease. [4]
Diagnosis
Episcleritis is diagnosed primarily on the basis of clinical findings. Slit-lamp examination shows edema of the episcleral tissue and injection of superficial episcleral vessels. [5, 6]
Clinicians should be alert to the possibility of malignancy or scleritis in these patients. Episcleritis can be the presenting sign of conjunctival lymphoma. [7] Scleritis is considerably less common than episcleritis, but more commonly is linked to connective tissue or vasculitis diseases and the development of ocular complications.
All patients require a thorough history, including a review of symptoms, and a physical examination. Results from these will establish the need for specific laboratory studies, which may be unnecessary in most patients with mild self-limited disease.
In certain patients with severe disease, the following laboratory studies may be useful:
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Serum uric acid
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Complete blood count with differential
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Antinuclear antibody
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Rheumatoid factor
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Erythrocyte sedimentation rate
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Venereal Disease Research Laboratory (VDRL) test
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Fluorescent treponemal antibody absorption (FTA-ABS) test
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Chest x-ray
Evaluate patients with a long history of low back pain or stiffness for ankylosing spondylitis.
Treatment
Artificial tears are helpful for patients with mild-to-moderate symptoms, and those with severe or prolonged episodes may need artificial tears and/or topical corticosteroids. Patients with nodular episcleritis may need local corticosteroid drops or anti-inflammatory agents. [6]
Systemic anti-inflammatory agents may be helpful in eyes that are unresponsive to topical therapy.
Systemic nonsteroidal anti-inflammatory drugs (NSAIDs) that may be given until inflammation is suppressed include flurbiprofen (100 mg tid), indomethacin (100 mg daily initially and decreased to 75 mg daily), and naproxen (220 mg up to 6 times per day). Naproxen 500 mg is reserved for patients with more severe episcleritis.
Patients who fail to respond or who have an incomplete response to both local therapy and systemic NSAIDs after 1 month may be treated with oral corticosteroids for a month or longer in a tapering dose. [6]
Those with episcleritis resulting from infection require appropriate antibiotic therapy.
Patient education, follow-up
Patients with photosensitivity may benefit from sunglasses.
Patients should be instructed to watch for the appearance of new systemic symptoms and should seek medical care to rule out a systemic disease if such symptoms occur.
Avoid long-term continuous treatment with steroid preparations because of the risk of causing cataract, glaucoma, and systemic complications. Excessive steroid use in these patients may increase the risk for recurrence.
Background
Episcleritis is an inflammatory condition affecting the episcleral tissue that lies between the conjunctiva and the sclera. [8, 9] It usually is a mild and self-limiting but recurrent disease. Most cases are idiopathic, although up to one third have an underlying systemic condition. Some cases may be caused by exogenous inflammatory stimuli. [10, 11, 12, 1]
Pathophysiology
The pathophysiology is poorly understood. The inflammatory response is localized to the superficial episcleral vascular network, and histopathology shows nongranulomatous inflammation with vascular dilatation and perivascular infiltration.
The two clinical types of episcleritis are diffuse and nodular/focal.
In diffuse episcleritis, the more common type, there are intermittent bouts of moderate-to-severe inflammation that often recur at 1- to 3-month intervals. The episodes usually last 7 to10 days, and most resolve after 2 to 3 weeks. Prolonged episodes may be more common in patients with associated systemic conditions. Some patients note that episodes are more common in the spring or fall. The precipitating factor is rarely found, but attacks have been associated with stress, allergy, trauma, and hormonal changes.
Patients with nodular/focal episcleritis have prolonged attacks of inflammation that are typically more painful than diffuse episcleritis. Many patients with nodular episcleritis have an associated systemic disease. [4]
Epidemiology
Diffuse episcleritis (84% of cases) is more common than nodular scleritis (16% of cases), and the mean age of all patients with episcleritis is 47.4 years. [5] Unilateral inflammation is seen in two thirds of patients with episcleritis. Episcleritis is more common in females than in males, although the difference is not statistically significant. [5, 6, 1]
Patient Education
Episcleritis is usually self-limited. The patient is usually comforted to know that it does not progress to a more serious disorder or result in loss of visual function.
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Localized temporal inflammation in a patient with nodular episcleritis.
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