BASICS
DESCRIPTION
• An inflammatory condition, usually mild and self-limiting, although it can be recurrent.
– Usually affects females, usually seen in young adults, up to 30% may have underlying systemic condition.
– Simple: Intermittent episodes of inflammation that resolve in 2–3 weeks.
– Nodular: Prolonged attacks, more painful, usually solitary nodule. Associated systemic disease more likely.
EPIDEMIOLOGY
Incidence
Difficult to determine, most patients do not seek medical attention (1).
Prevalence
Unknown.
RISK FACTORS
• Underlying systemic condition such as collagen vascular disease (rheumatoid arthritis, lupus, etc.) (1)
– Can be associated with infection such as Lyme disease, syphilis.
– Stress, hormonal changes may be associated.
PATHOPHYSIOLOGY
Not clearly understood, thought to be an inflammatory response to an inciting event.
ETIOLOGY
• Idiopathic
• Underlying systemic condition or infection
COMMONLY ASSOCIATED CONDITIONS
• Collagen vascular diseases
• Gout
• Herpes zoster or simplex
• Rosacea
DIAGNOSIS
HISTORY
Acute onset of redness, irritation, tearing; can be diffuse or sectorial.
PHYSICAL EXAM
• Sectorial or diffuse hyperemia, or localized injected nodule over bulbar conjunctiva seen at slit-lamp examination
• Area of injection or nodule can be freely moved over sclera using cotton tip applicator after topical anesthesia.
• 10% may have associated anterior uveitis.
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Initial lab tests
• Topical 2.5% phenylephrine will blanch inflamed vessels in simple episcleritis (2)[C].
• Additional systemic testing dependent on review of systems.
Follow-up & special considerations
If severe, recurrent, or nodular episcleritis, check serum uric acid, CBC with differential, ANA, RF, ESR, CXR, VDRL, and FTA-ABS.
Pathological Findings
Histopathology shows nongranulomatous inflammation with vascular dilatation and perivascular infiltrates of lymphocytes and plasma cells.
DIFFERENTIAL DIAGNOSIS
• Bacterial or viral conjunctivitis
• Scleritis
• Pingueculitis
TREATMENT
MEDICATION
First Line
Artificial tears, cool compresses at least 4 times a day.
Second Line
Short course of topical antihistamine or NSAID 2–4 times a day.
ADDITIONAL TREATMENT
General Measures
• Oral NSAID for moderate to severe cases (e.g., indomethacin 75—100 mg per day) (3)
– Short course of topical steroid 4 times a day
Geriatric Considerations
Side effects of long term topical steroid use include cataract formation and glaucoma.
Pediatric Considerations
Side effects of long term topical steroid use include cataract formation and glaucoma.
Pregnancy Considerations
Topical NSAIDs and steroids are class C and of unknown safety in lactation.
Issues for Referral
Associated corneal changes, resistant to treatment, recurrent.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Follow up for recurrent episodes.
Patient Monitoring
Usually self-limiting condition.
PROGNOSIS
Favorable to good.
REFERENCES
1. Akpek EK, Uy H, Christen W, et al. Severity of episcleritis and systemic disease association. Ophthalmology 1999;106:729–731.
2. Okhravi N, Odufuwa B, McCluskey P, et al. Scleritis. Surv Ophthalmol 2005;50:351–363.
3. Jabs DA, Mudun A, Dunn JP, et al. Episcleritis and scleritis: Clinical features and treatment results. Am J Ophthalmol. 2000;130:469–476.
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