What is the recommended treatment for episcleritis?

Treatment of Episcleritis

The recommended first-line treatment for episcleritis is topical corticosteroids and/or topical NSAIDs, with mild cases potentially self-resolving without intervention. 1

Diagnosis and Classification

Before initiating treatment, it's important to correctly diagnose episcleritis and distinguish it from scleritis:

• Episcleritis: Inflammation limited to the episclera (superficial layer)

  • Characterized by mild pain, redness, and hyperemia of the conjunctiva and episclera
  • May present with itching or burning sensation
  • Usually no visual changes or disturbances

• Key diagnostic features:

  • Hyperemic sclera and conjunctiva
  • Mild to moderate pain
  • Preserved visual acuity
  • Absence of photophobia or severe pain (which would suggest uveitis or scleritis)

Treatment Algorithm Based on Severity

Grade 1 (Asymptomatic/Mild)

• Continue any ongoing immunotherapy if applicable 1
• Ophthalmology referral within 1 week
• Start lubrication drops (artificial tears)
• May self-resolve without intervention 1

Grade 2 (Symptomatic)

• Hold immunotherapy if applicable 1
• Ophthalmology referral within 2 days
• Treatment options:
  1. Topical corticosteroids (first-line)
  2. Topical NSAIDs
  3. Oral NSAIDs for more resistant cases
  4. Consider cycloplegic agents if recommended by ophthalmologist 1

Grade 3-4 (Severe)

• Permanently discontinue immunotherapy if applicable 1
• URGENT ophthalmology referral (preferably uveitis specialist)
• Treatment options:
  1. Topical steroids
  2. Systemic steroids
  3. Consider immunomodulatory therapy in resistant cases 1

Treatment Specifics

1. Topical Treatments:

   • Topical corticosteroids (prednisolone acetate 1%)
   • Topical NSAIDs
   • Artificial tears for lubrication

2. Systemic Treatments (for resistant cases):

   • Oral NSAIDs (e.g., diclofenac sodium)
   • Systemic corticosteroids (for severe or resistant cases)

3. Advanced Therapy (for refractory cases):

   • Immunomodulatory therapy
   • Anti-TNF agents may be considered in severe refractory cases 1

Important Considerations

• Underlying Conditions: Episcleritis may be associated with systemic diseases, particularly inflammatory bowel disease and rheumatoid arthritis 1
• Warning Signs: Visual disturbance, photophobia, moderate to severe pain suggest more serious conditions (scleritis or uveitis) requiring urgent ophthalmological referral 1
• Caution: Do not start steroid treatment prior to ophthalmological examination if infection is suspected, as this may worsen conditions like herpetic keratitis/uveitis 1

Follow-up

• Most cases of episcleritis are self-limiting and resolve within 2-3 weeks 2
• Regular follow-up is recommended to monitor response to treatment
• If symptoms worsen or don't improve with initial therapy, reassessment by an ophthalmologist is necessary

Treatment Pitfalls to Avoid

1. Failing to distinguish between episcleritis and scleritis (which requires more aggressive treatment)
2. Starting steroid treatment without ruling out infectious causes
3. Inadequate follow-up for recurrent or persistent cases
4. Not addressing underlying systemic conditions that may be causing recurrent episcleritis

Episcleritis generally has a good prognosis with appropriate treatment, with significantly fewer ocular complications (13.5%) compared to scleritis (58.8%) 3.