Treatment of Episcleritis
For mild episcleritis, start with artificial tears (lubrication drops) and consider topical corticosteroids or NSAIDs for symptomatic relief; most cases are self-limited and benign. 1
First-Line Treatment
The initial management of episcleritis depends on severity but generally follows a conservative approach:
Mild/Asymptomatic Cases (Grade 1)
- Artificial tears/lubrication drops as primary therapy 2
- Observation is appropriate as episcleritis often self-resolves 1
- Continue monitoring without aggressive intervention
- Ophthalmology referral within 1 week if symptoms persist 2
Symptomatic Cases (Grade 2)
- Topical corticosteroids (e.g., prednisolone acetate 1%) for symptomatic relief 1
- Topical NSAIDs as an alternative or adjunct for analgesia 1
- Systemic NSAIDs (e.g., diclofenac sodium) can be added for more significant inflammation 1
- Ophthalmology referral within 2 days before initiating treatment 2
The European consensus guidelines emphasize that episcleritis responds well to management of any underlying systemic disease (particularly inflammatory bowel disease) combined with topical therapy 1. A 1990 randomized trial showed that topical prednisolone 0.3% had significantly higher cure rates than placebo or topical flurbiprofen after 3 weeks, though spontaneous improvement occurred in most cases 3.
Second-Line Treatment
For Refractory or Recurrent Cases
When first-line therapy fails or symptoms recur:
- Systemic corticosteroids may be required in severe cases 2
- Topical tacrolimus 0.1% has shown dramatic efficacy in steroid-resistant nodular episcleritis, though this represents off-label use 4
- Disease-modifying anti-rheumatic drugs (DMARDs) or anti-TNF biologics (infliximab, adalimumab) for cases associated with rheumatoid arthritis or other systemic inflammatory conditions 5
Severe Cases with Visual Compromise (Grade 3-4)
- Urgent ophthalmology referral (preferably uveitis specialist) 2
- Systemic corticosteroids in addition to topical/periocular steroids 2
- Consider permanent discontinuation of immune checkpoint inhibitors if drug-induced 2, 6
Critical Clinical Distinctions
Differentiate episcleritis from scleritis before treatment, as this fundamentally changes management:
- Episcleritis: Mild pain, hyperemia of conjunctiva/episclera, NO visual changes, benign course 1
- Scleritis: Moderate-to-severe pain, visual disturbance, photophobia, requires aggressive treatment to prevent vision loss 1, 7, 8
Use slit-lamp examination to assess for inflammatory cells and confirm the diagnosis 1. The 10% phenylephrine test can help distinguish between the two: episcleral vessels blanch with phenylephrine, while deeper scleral vessels do not.
Important Caveats
- Do NOT start corticosteroids before ophthalmology examination if infection is possible, as steroids can worsen infectious conditions (e.g., herpetic keratitis) or mask accurate diagnosis 2
- Exclude infectious scleritis in patients with history of ocular surgery, trauma, or poor contact lens hygiene before initiating immunosuppressive therapy 9
- Up to 50% of scleritis/episcleritis cases have associated systemic disease (rheumatoid arthritis, granulomatosis with polyangiitis, inflammatory bowel disease), warranting systemic workup with blood tests and imaging 7, 5
- Nodular episcleritis tends to be more painful and prolonged than diffuse forms 4
Treatment Algorithm Summary
- Confirm diagnosis via slit-lamp examination (rule out scleritis/infection)
- Mild cases: Artificial tears ± topical corticosteroids/NSAIDs
- Moderate cases: Add systemic NSAIDs
- Refractory cases: Consider tacrolimus, systemic steroids, or DMARDs
- Investigate underlying systemic disease if recurrent or severe
The key principle is that episcleritis is fundamentally benign and often self-limited, requiring only symptomatic treatment in most cases, whereas any suspicion of scleritis demands aggressive anti-inflammatory therapy to prevent permanent vision loss 7, 8.