From the Guidelines
Episcleritis and scleritis should be treated with topical or systemic NSAIDs, topical corticosteroids, and in severe cases, immunosuppressants, with scleritis requiring more aggressive management due to its potential for vision loss. The treatment approach for these conditions is largely based on symptom management and the severity of the disease. For episcleritis, which may self-resolve, topical or systemic NSAIDs or topical corticosteroids can be used for symptomatic treatment 1.
Key Considerations for Treatment
- Episcleritis may respond to management of the underlying bowel disease, along with the addition of topical NSAIDs for analgesia and glucocorticoids 1.
- Scleritis, being more severe, requires treatment guided by an ophthalmologist, which can include topical or systemic corticosteroids, conventional immunosuppressants, and anti-TNF agents 1.
- Dry eyes, a common symptom, can be treated with topical lubricants.
- Anterior uveitis should be treated with topical corticosteroids and cycloplegics.
Treatment Approach
- For episcleritis, initial treatment involves topical lubricants and oral NSAIDs like ibuprofen or naproxen for 1-2 weeks.
- For persistent episcleritis, topical steroids such as prednisolone acetate 1% or fluorometholone 0.1% may be used.
- Scleritis treatment starts with oral NSAIDs at maximum doses but often requires oral corticosteroids, with severe cases necessitating immunosuppressive agents under specialist supervision.
- Given the potential association with underlying systemic autoimmune diseases, patients should undergo appropriate testing and may need a rheumatology referral, especially for scleritis due to its severity and risk of vision loss.
From the Research
Diagnosis of Episcleritis and Scleritis
- Episcleritis is a benign disease that only affects the episclera, whereas scleritis is an ocular inflammation that can cause severe pain and 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.
- A systemic disease, such as rheumatoid arthritis or granulomatosis with polyangiitis, is associated with up to 50% of all patients with scleritis or episcleritis, making a systemic work-up and collaboration with internists necessary 2.
Treatment of Episcleritis and Scleritis
- Episcleritis has a self-limited course, whereas treatment of scleritis is obligatory to protect patients from irreversible visual loss, organ damage, and reduce the risk of mortality 2.
- Treatment of scleritis may involve non-steroidal anti-inflammatory drugs, corticosteroids, and disease-modifying anti-rheumatic drugs, depending on the subtype and associated systemic disease 2, 3.
- Corticosteroids remain the mainstay of short-term treatment of scleritis, while mild to moderate scleral inflammation may respond well to treatment with nonsteroidal anti-inflammatory drugs or topical corticosteroids 3.
- Corticosteroid-sparing immunosuppressive therapies and biologic agents are useful in cases with an inadequate response or failure to provide long-term control of inflammation, and to prevent recurrence of scleritis 3.