What is the treatment for episcleritis?

Treatment of Episcleritis

Episcleritis is typically self-limiting and can be effectively managed with topical NSAIDs or topical corticosteroids, while addressing any underlying systemic condition. 1

Diagnosis and Clinical Presentation

Episcleritis is an inflammatory condition affecting the episclera, the thin layer of tissue between the conjunctiva and sclera. It presents with:

• Hyperemia (redness) of the conjunctiva and episclera
• Mild pain or burning sensation
• Itching
• Usually no visual changes or disturbance
• May be sectoral or diffuse

Differentiating episcleritis from scleritis is crucial as their management differs significantly:

• Episcleritis: Usually mild pain, no visual disturbance, superficial episcleral vessel involvement
• Scleritis: Often severe pain, may have visual disturbance, deeper vessel involvement

Treatment Algorithm

First-line Treatment

1. Self-resolution monitoring

   • Episcleritis may self-resolve without intervention 1
   • Artificial tears can be used for symptomatic relief 1

2. Topical therapy

   • Topical NSAIDs for analgesia and inflammation control 1
   • Topical corticosteroids for more symptomatic cases 1

Second-line Treatment

1. Systemic NSAIDs for cases not responding to topical therapy 1, 2
   • Only about 16.7% of episcleritis patients require systemic NSAIDs 2

For Refractory Cases

1. Ophthalmology referral for cases not responding to standard therapy 1
2. Consider alternative agents like tacrolimus for steroid-resistant cases 3

Special Considerations

Associated Systemic Conditions

• Up to 30% of episcleritis cases may be associated with systemic diseases 4
• Common associations include:
  • Inflammatory bowel disease 1
  • Rheumatoid arthritis 5
  • Other autoimmune conditions

Immune Checkpoint Inhibitor-Related Episcleritis

For patients on immunotherapy:

• Grade 1 (asymptomatic): Continue immunotherapy, use lubrication drops, refer to ophthalmology within 1 week 1
• Grade 2 (symptomatic): Hold immunotherapy, refer to ophthalmology within 2 days, coordinate treatment with specialist 1
• Grade 3-4 (severe): Permanently discontinue immunotherapy, urgent ophthalmology referral 1

Monitoring and Follow-up

• Most cases resolve within 2-3 weeks with appropriate treatment
• Monitor for:
  • Resolution of symptoms
  • Development of ocular complications (rare in episcleritis, occurring in only 13.5% of cases) 2
  • Recurrence (episcleritis can have a recurrent course) 4

Important Caveats

1. Do not start treatment before ophthalmologic examination in unclear cases, as steroids may worsen infectious conditions or mask accurate diagnosis 1

2. Visual disturbance, photophobia, or moderate to severe pain should prompt urgent ophthalmology referral to rule out scleritis or uveitis 1

3. Differentiate from scleritis, which requires more aggressive treatment and has worse outcomes (58.8% complication rate vs. 13.5% for episcleritis) 2

4. Unlike scleritis, episcleritis rarely causes decrease in visual acuity 2

5. Treatment of underlying systemic disease may help control episcleritis when associated with conditions like inflammatory bowel disease 1