What are the latest treatment guidelines for managing autoimmune episcleritis?

Management of Autoimmune Episcleritis

For autoimmune episcleritis, start with topical NSAIDs or topical corticosteroids for symptomatic relief, as the condition often self-resolves; reserve systemic NSAIDs for cases requiring additional analgesia, and escalate to systemic corticosteroids or immunosuppressants only if the condition is refractory or associated with active systemic disease. 1

Initial Assessment and Diagnosis

When evaluating suspected episcleritis, differentiate it from more serious scleritis by looking for:

• Mild pain with conjunctival and episcleral hyperemia without visual changes (characteristic of episcleritis) 1
• Absence of photophobia, severe pain, or visual disturbance (which would suggest scleritis requiring urgent ophthalmology referral) 1

Refer immediately to ophthalmology for slit-lamp examination if the patient has:

• Visual disturbance or acuity worse than 20/40 1
• Photophobia or moderate-to-severe pain 1
• Any concern for inflammatory cells or progression to scleritis 1

First-Line Treatment Approach

The treatment hierarchy for autoimmune episcleritis follows this algorithm:

Mild Cases (No Visual Compromise)

• Topical NSAIDs for analgesia 1
• Topical corticosteroids (e.g., prednisolone acetate 1%) 1, 2
• Artificial tears/topical lubricants for symptomatic relief 1
• Continue immune checkpoint inhibitors if applicable, as most cases are manageable with topical therapy alone 1

Moderate Cases (Persistent Symptoms)

• Systemic NSAIDs (e.g., diclofenac sodium) for additional analgesia 1, 2
• Address underlying systemic disease activity - episcleritis often responds when the underlying autoimmune condition (IBD, SLE, RA) is controlled 1, 3

Management of Refractory Cases

For steroid-resistant nodular episcleritis:

• Topical tacrolimus 0.1% four times daily has shown dramatic efficacy in steroid-resistant cases 2
• This represents an important alternative when conventional topical corticosteroids fail 2

For severe or recurrent episcleritis with systemic involvement:

• Systemic corticosteroids are indicated when there is active systemic autoimmune disease (SLEDAI >4 in SLE patients) 3
• Immunosuppressants (cyclophosphamide, leflunomide, or hydroxychloroquine) should be considered for patients with active underlying rheumatic disease 4, 3
• Anti-TNF biologics (infliximab, adalimumab) are recommended for refractory cases, particularly in RA-associated disease 4
• Rituximab may be effective in treatment-resistant cases 4

Critical Pitfalls to Avoid

Do not delay ophthalmology referral if visual acuity drops below 20/40 or if there are signs suggesting progression to scleritis, as complications occur in only 13.5% of episcleritis cases but 58.8% of scleritis cases 5

Do not start corticosteroids before ophthalmologic examination in immune checkpoint inhibitor-related cases, as this may worsen infectious causes (e.g., herpetic keratitis) or mask accurate diagnosis 1

Hold immune checkpoint inhibitors for grade 2 or higher episcleritis (symptomatic with visual acuity 20/40 or better) until ophthalmology evaluation is complete 1

Permanently discontinue immune checkpoint inhibitors for grade 3-4 episcleritis (visual acuity worse than 20/40 or blindness) 1

Context-Specific Considerations

In inflammatory bowel disease (IBD): Episcleritis typically correlates with bowel disease activity and responds to management of the underlying IBD 1

In systemic lupus erythematosus (SLE): Episcleritis may indicate active systemic disease requiring intensification of systemic immunosuppression 3

In rheumatoid arthritis (RA): Close coordination between rheumatology and ophthalmology is essential, as scleritis may be the first indicator of rheumatoid vasculitis 4

In immune checkpoint inhibitor therapy: Most cases are mild (grade 1-2) and manageable with topical therapy while continuing immunotherapy 1