para>Recurrent episodes, difficulty confirming the diagnosis, or worsening symptoms require prompt ophthalmology referral (2)[C].
DIFFERENTIAL DIAGNOSIS
- Scleritis
- Bacterial conjunctivitis
- Viral conjunctivitis
- Herpes (ulcerative) keratitis
- Superficial keratitis
- Increased intraocular pressure (ocular hypertension)
DIAGNOSTIC TESTS & INTERPRETATION
Most patients with episcleritis do not require any further lab work or diagnostic studies (5)[C]
TREATMENT
MEDICATION
Treatment for episcleritis typically consist of symptomatic relief. The goal is to suppress the inflammation, which will, in turn, relieve the discomfort or pain. In most cases, treatment is not needed.
First Line
Topical lubricants such as artificial tears are typically used for initial management of symptomatic episcleritis (2)[C].
Second Line
- Topical corticosteroids are useful when discomfort is not sufficiently controlled by conservative measures (2,5,6)[C].
- Fluorometholone 0.1% drops 4 times daily; if not effective, may increase frequency
- Prednisolone 0.5-1% eye drops
- Refractory episcleritis may be treated with oral NSAIDs, typically indomethacin 25 mg 3 or 4 times daily (5)[C].
ISSUES FOR REFERRAL
Recurrent episodes, uncertain diagnosis, and/or worsening symptoms should prompt ophthalmology referral. Rarely, episcleritis may progress to scleritis in which case ophthalmology referral is also recommended.
ADDITIONAL THERAPIES
- Topical NSAIDs have not been shown to have a significant benefit over artificial tears (7)[B].
- When episcleritis results from viral infection, appropriate antiviral therapy is indicated (6)[C].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Episcleritis is usually self-limited (up to 21 days) and does not typically require follow-up.
PROGNOSIS
- Most patients have no ocular complications.
- Prognosis for episcleritis is excellent, with most patients making a full recovery.
COMPLICATIONS
Associated complications are rare, even at tertiary care referral centers, where referral bias likely overestimates their community incidence. When complications do occur, they tend not to be severe.
- Anterior uveitis may occur in 4-16% of cases (1,5,6)[C].
- Decreased vision may occur in 0-4% of cases (1,5,6)[C].
- Ocular hypertension has been reported in 0-3.5% of cases (1,5,6)[C].
REFERENCES
11 Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA, et al. Clinical characteristics of a large cohort of patients with scleritis and episcleritis. Ophthalmology. 2012;119(1):43-50.22 Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010;81(2):137-144.33 Garrity JA. Ocular manifestations of small-vessel vasculitis. Cleve Clin J Med. 2012;79(Suppl 3):S31-S33.44 Galor A, Thorne JE. Scleritis and peripheral ulcerative keratitis. Rheum Dis Clin North Am. 2007;33(4):835-854.55 Jabs DA, Mudun A, Dunn JP, et al. Episcleritis and scleritis: clinical features and treatment results. Am J Ophthalmol. 2000;130(4):469-476.66 Berchicci L, Miserocchi E, Di Nicola M, et al. Clinical features of patients with episcleritis and scleritis in an Italian tertiary care referral center. Eur J Ophthalmol. 2014;24(3):293-298.77 Williams CP, Browning AC, Sleep TJ, et al. A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis. Eye (Lond). 2005;19(7):739-742.
ADDITIONAL READING
- Homayounfar G, Borkar DS, Tham VM, et al. Clinical characteristics of scleritis and episcleritis: results from the Pacific Ocular Inflammation Study. Ocul Immunol Inflamm. 2014;22(5):403-404.
- Homayounfar G, Nardone N, Borkar DS, et al. Incidence of scleritis and episcleritis: results from the Pacific Ocular Inflammation Study. Am J Ophthalmol. 2013;156(4):752-758.
- Honik G, Wong IG, Gritz DC. Incidence and prevalence of episcleritis and scleritis in Northern California. Cornea. 2013;32(12):1562-1566.
CODES
ICD10
- H15.109 Unspecified episcleritis, unspecified eye
- H15.129 Nodular episcleritis, unspecified eye
- H15.102 Unspecified episcleritis, left eye
- H15.101 Unspecified episcleritis, right eye
- H15.103 Unspecified episcleritis, bilateral
- H15.123 Nodular episcleritis, bilateral
- H15.122 Nodular episcleritis, left eye
- H15.121 Nodular episcleritis, right eye
ICD9
- 379.00 Scleritis, unspecified
- 379.02 Nodular episcleritis
- 379.09 Other scleritis and episcleritis
SNOMED
- 815008 Episcleritis (disorder)
- 70558001 Nodular episcleritis
- 231873005 Simple episcleritis
CLINICAL PEARLS
- Episcleritis typically is a benign, self-limited disorder.
- Is often not painful and presents without decrease in visual acuity
- Although treatment is often not needed, when employed, the goal is symptomatic relief while awaiting spontaneous resolution.
- Topical lubricants and/or topical corticosteroid treatment may relieve symptoms.
- Associated complications are uncommon and not severe but may include anterior uveitis, decreased vision, and ocular hypertension.
- Episcleritis can be an early presentation of scleritis, which is more severe. Accurate diagnosis of episcleritis is important.