What is episcleritis?

From the Guidelines

Episcleritis can be effectively managed with topical NSAIDs or topical corticosteroids for symptomatic treatment, and in many cases, it may self-resolve. The treatment approach should prioritize the management of underlying conditions, such as inflammatory bowel disease, and the use of topical agents for symptomatic relief [ 1 ].

Key Considerations

• Episcleritis is often associated with underlying systemic conditions, and its management should consider the treatment of these conditions [ 1 ].
• Topical NSAIDs, such as ketorolac 0.5% drops, can be used to reduce inflammation and pain in more severe cases [ 1 ].
• Topical corticosteroids, like prednisolone acetate 1%, may be prescribed for short courses under ophthalmological supervision due to potential side effects [ 1 ].
• It is crucial to distinguish episcleritis from the more severe condition of scleritis, which requires different treatment and may affect vision [ 1 ].

Treatment Approach

• For symptomatic relief, artificial tears can be used frequently, and cold compresses may be applied to the affected eye [ 1 ].
• In cases associated with inflammatory bowel disease, the treatment of episcleritis should parallel the management of the underlying condition [ 1 ].
• Referral to an ophthalmologist is not typically required for simple episcleritis but is necessary for more severe ocular manifestations like uveitis [ 1 ].

From the Research

Definition and Classification

• Episcleritis is a benign disease that only affects the episclera, whereas scleritis is an ocular inflammation with severe pain that can affect adjacent tissue 2.
• Scleritis is classified into anterior and posterior forms, with anterior scleritis further subdivided into diffuse, nodular, necrotizing with inflammation, and necrotizing scleritis without inflammation (scleromalacia perforans) 2.

Clinical Features

• Episcleritis has a self-limited course, whereas scleritis requires obligatory treatment to protect patients from irreversible visual loss, organ damage, and reduce the risk of mortality 2.
• Ocular complications occur in only 13.5% of patients with episcleritis, but in 58.8% of patients with scleritis 3.
• No patient with episcleritis had a decrease in visual acuity, whereas 15.9% of patients with scleritis did 3.

Treatment

• Treatment of episcleritis and scleritis depends on the subtype and associated systemic disease, and may involve non-steroidal anti-inflammatory drugs, corticosteroids, and disease-modifying anti-rheumatic drugs 2.
• Topical steroid therapy can be considered as first-line treatment for nonnecrotizing anterior scleritis, especially in cases where the likelihood of complications from systemic steroid or NSAID therapy is high 4.
• Topical ketorolac is not significantly better than artificial tears in treating the signs or symptoms of idiopathic episcleritis 5.
• The treatment of scleritis should be managed by physicians who are experts in the use of immunosuppressive drugs, which may be required in one out of two affected patients 6.

Associated Systemic Disease

• A systemic disease such as rheumatoid arthritis or granulomatosis with polyangiitis is associated with up to 50% of all patients with scleritis or episcleritis 2.
• The risk of associated systemic disease and visual loss is highly variable according to the type of scleritis, and culminates at 80% and 50% in the necrotizing subtype respectively 6.