From the Guidelines
When evaluating episcleritis for potential underlying autoimmune disease, a comprehensive workup should be initiated, especially in cases of recurrent episodes or bilateral involvement, to identify associated systemic conditions and prevent complications in other organ systems. The initial assessment should include a complete blood count, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, antinuclear antibody, and anti-neutrophil cytoplasmic antibodies 1. Additional testing may include HLA-B27, serum uric acid levels, and specific antibodies like anti-CCP for rheumatoid arthritis. Urinalysis and chest X-ray may help identify systemic conditions like granulomatosis with polyangiitis or sarcoidosis.
Key Considerations
- Episcleritis may be self-limiting and idiopathic, but approximately 30-40% of cases are associated with systemic conditions including rheumatoid arthritis, lupus, inflammatory bowel disease, and various vasculitides 1.
- Early identification of underlying autoimmune disease allows for appropriate systemic treatment, which not only addresses the ocular inflammation but also manages the underlying condition, potentially preventing complications in other organ systems.
- Treatment of the underlying autoimmune condition often resolves the episcleritis more effectively than topical treatments alone.
Diagnostic Approach
- Consultation with rheumatology is recommended for patients with positive findings or recurrent episodes 1.
- Ophthalmologic referral is necessary for patients with suspected uveitis or scleritis, as these conditions can have severe consequences if left untreated 1.
- Slit-lamp examination can confirm the diagnosis and permit the differentiation between anterior and posterior uveitis 1.
Management
- Topical corticosteroids and NSAIDs may be effective in treating episcleritis, especially in cases associated with inflammatory bowel disease 1.
- Systemic corticosteroids, immunosuppressive therapy, and anti-TNF agents may be necessary for resistant cases or for treating underlying autoimmune conditions 1.
From the Research
Workup for Autoimmune Disease in Episcleritis
The workup for autoimmune disease in a patient with episcleritis involves several steps:
- Clinical diagnosis: The diagnosis of episcleritis is essentially clinical, and eye pain or tenderness should raise the concern for scleritis 2.
- Bloodwork: Bloodwork to diagnose associated systemic rheumatological disease may be helpful 2.
- Systemic work-up: A systemic work-up with blood sampling and imaging as well as collaboration with internists are necessary to rule out underlying systemic diseases 3.
- Collaboration with internists: Collaboration between ophthalmologists and internists (or rheumatologists) is necessary for the medical management of scleritis and episcleritis 4, 5.
Associated Systemic Diseases
Episcleritis and scleritis can be associated with various systemic autoimmune diseases, including:
- Rheumatoid arthritis 6, 3, 4, 5
- Inflammatory bowel disease 6, 4
- Systemic lupus erythematosus 6, 4
- Polyangiitis with granulomatosis 6
- Granulomatosis with polyangiitis (Wegener's) 4, 5
- Polychondritis 4
Treatment
Treatment of episcleritis and scleritis depends on the subtype and associated systemic disease, and may involve: