Initial Treatment for Episcleritis
For simple episcleritis, initial treatment consists of topical NSAIDs for symptomatic relief and/or topical corticosteroids, with the understanding that the condition may self-resolve without intervention. 1
Treatment Algorithm
First-Line Approach
- Topical NSAIDs are the preferred initial therapy for symptomatic relief of pain, itching, and burning 1
- Topical corticosteroids (such as prednisolone acetate 1%) can be used as an alternative or adjunct, instilled 2-4 times daily initially 1, 2
- Observation alone is reasonable, as episcleritis frequently self-resolves without treatment 1
When to Escalate Treatment
- If symptoms persist beyond 2 days of topical therapy, re-evaluate the patient to ensure the diagnosis is correct and not scleritis or uveitis 2
- Oral NSAIDs (such as diclofenac sodium) may be added for more symptomatic cases or those not responding to topical therapy alone 3, 4
- In one Italian tertiary center study, 76% of episcleritis patients achieved resolution with topical corticosteroids alone, while only 16% required oral NSAIDs 3
Address Underlying Disease
- Treat the underlying bowel disease if episcleritis occurs in the context of inflammatory bowel disease, as episcleritis tends to reflect IBD activity 1
- Episcleritis associated with IBD typically responds to management of the intestinal inflammation 1
Critical Differentiation: When NOT to Treat as Simple Episcleritis
Red Flags Requiring Ophthalmology Referral
- Moderate to severe eye pain (suggests scleritis, not episcleritis) 1
- Photophobia (suggests uveitis or scleritis) 1
- Blurred vision or diminished visual acuity (suggests sight-threatening condition) 1
- Visual disturbance of any kind (requires slit-lamp examination) 1, 5
Key Clinical Distinction
- Episcleritis presents with mild or no pain, hyperemic sclera and conjunctiva, itching and burning, but no visual changes 1, 5
- Scleritis presents with severe pain and often has a "cloudy" or discolored appearance of the sclera 6
- This distinction is critical because scleritis requires urgent systemic treatment to prevent vision loss, while episcleritis can be managed conservatively 7, 4
Common Pitfalls to Avoid
Do Not Delay Ophthalmology Referral
- Simple episcleritis does not require ophthalmology referral if clearly differentiated from more serious conditions 1
- However, when differentiation is uncertain, refer to an ophthalmologist with expertise in ocular inflammatory disease 1
- The presence of severe pain should immediately raise concern for scleritis rather than episcleritis 6
Do Not Discontinue Therapy Prematurely
- When using topical corticosteroids, taper gradually over 6-8 weeks rather than stopping abruptly 2, 8
- Premature discontinuation may lead to rebound inflammation 2
Recognize Steroid-Resistant Cases
- While rare, some nodular episcleritis cases may be steroid-resistant and require alternative immunomodulatory therapy such as topical tacrolimus 0.1% 8
- If symptoms relapse at the end of standard treatment course, consider this possibility 8
Systemic Workup Considerations
- An associated systemic disease is found in approximately 20% of episcleritis patients 3
- However, unlike scleritis (which requires extensive systemic evaluation), simple episcleritis without concerning features does not mandate immediate systemic workup 7, 3
- Consider systemic evaluation if episcleritis is recurrent, bilateral, or associated with other systemic symptoms 9, 3