What is the treatment for episcleritis (inflammation of the episclera) secondary to rheumatoid arthritis (RA)?

Treatment of Episcleritis Secondary to Rheumatoid Arthritis

Episcleritis in rheumatoid arthritis should be treated with topical corticosteroids or NSAIDs alongside optimization of the underlying RA disease control, as it typically parallels disease activity and responds well to local therapy without requiring systemic immunosuppression. 1

Initial Management Approach

First-Line Therapy

• Topical corticosteroids or topical NSAIDs are the mainstay of treatment for RA-associated episcleritis 1
• Artificial tears provide symptomatic relief and should be used liberally 1, 2
• Cold compresses can help reduce inflammation and discomfort 2
• Simple episcleritis may be self-limiting and can resolve without intervention in 1-3 months 1, 2

Disease Activity Correlation

• Episcleritis in RA generally parallels underlying disease activity, so optimizing RA treatment is essential 1
• Treatment of the underlying RA with DMARDs (disease-modifying antirheumatic drugs) should be ensured 3
• The condition often improves when systemic RA inflammation is controlled 1

When to Escalate Treatment

Oral NSAIDs

• Oral NSAIDs should be considered for persistent or recurrent symptoms that don't respond to topical therapy 1, 3
• Use at the minimum effective dose for the shortest duration due to cardiovascular and gastrointestinal risks 4
• For patients ≥75 years, topical NSAIDs are strongly preferred over oral formulations 4

Systemic Corticosteroids

• Systemic steroids are rarely necessary for isolated episcleritis 2
• May be required if episcleritis is part of broader systemic RA flare 1
• Should be used as temporary adjunctive therapy (<6 months) at the lowest effective dose 4

Refractory Cases

• Immunosuppressive therapy including anti-TNF agents (infliximab, adalimumab) may be helpful in resistant cases, though this is more commonly needed for scleritis than episcleritis 1, 3
• Consider escalating systemic RA therapy rather than treating the eye in isolation 3

Critical Differentiation: Episcleritis vs. Scleritis

Red Flags Requiring Urgent Ophthalmology Referral

• Severe eye pain or tenderness suggests scleritis, not episcleritis 5, 6, 2
• Decreased visual acuity (vision <20/40) 1, 7
• Sudden increase in floaters or visual field loss 7
• Metamorphopsia (distorted vision) 7

Why This Matters

• Scleritis requires aggressive systemic anti-inflammatory treatment and carries risk of vision loss, while episcleritis is benign 5, 6
• Scleritis in RA patients is more likely to be diffuse or necrotizing and may indicate underlying rheumatoid vasculitis 3
• 2% of RA patients develop scleritis, which requires fundamentally different management than episcleritis 3

Ophthalmology Referral Guidelines

When Referral is Optional

• Simple episcleritis does not require ophthalmology referral if diagnosis is clear and symptoms are mild 1
• Can be managed in primary care or rheumatology setting with topical therapy 1

When Referral is Mandatory

• Any suspicion of scleritis (severe pain, deep injection, vision changes) 1, 2
• Persistent or recurrent episcleritis despite appropriate topical therapy 1
• Nodular episcleritis, which tends to be more recurrent and painful 2
• Any visual compromise warrants urgent evaluation 1

Monitoring and Follow-Up

Treatment Response Assessment

• Episcleritis typically improves within 1-3 weeks with appropriate therapy 2
• If no improvement after 2-4 weeks of topical therapy, reassess diagnosis and consider ophthalmology referral 4
• Monitor for recurrence, as nodular forms are more likely to recur 2

Systemic Workup Considerations

• While most episcleritis cases are idiopathic, up to 50% of scleritis cases have associated systemic disease 6
• In known RA patients, additional systemic workup is generally not needed unless scleritis is suspected 6
• Close cooperation between rheumatology and ophthalmology is essential, especially if scleritis develops as it may indicate rheumatoid vasculitis 3

Common Pitfalls to Avoid

• Do not mistake scleritis for episcleritis - the presence of severe pain should immediately raise concern for scleritis 5, 2
• Do not use systemic immunosuppression for simple episcleritis - topical therapy is sufficient in most cases 1
• Do not ignore the underlying RA disease activity - episcleritis often reflects inadequate systemic control 1
• Do not delay ophthalmology referral if there is any diagnostic uncertainty or vision-threatening features 1