Workup for Episcleritis
Initial Clinical Assessment
Most cases of episcleritis are idiopathic and require minimal workup, but a targeted systemic evaluation is warranted when clinical features suggest underlying autoimmune disease, particularly inflammatory bowel disease or rheumatoid arthritis. 1, 2
Distinguish Episcleritis from Scleritis First
This is the most critical initial step, as it fundamentally changes management:
- Episcleritis presents with mild or no pain, superficial vessel hyperemia, and preserved vision 2
- Scleritis causes severe pain, deep vessel injection, photophobia, and potential vision loss 3, 2
- If severe pain, visual disturbance, or photophobia are present, urgent ophthalmology referral for slit-lamp examination is mandatory 3
Clinical History to Obtain
Focus on these specific systemic associations:
- Gastrointestinal symptoms: diarrhea, abdominal pain, bloody stools (IBD occurs in 4-12% of episcleritis cases) 3, 2
- Joint symptoms: morning stiffness, polyarticular pain (rheumatoid arthritis is a leading cause) 1, 2
- Systemic vasculitis symptoms: constitutional symptoms, rash, renal involvement 4
- Recurrence pattern: nodular forms recur more frequently 1
Laboratory Workup Strategy
For Simple, Unilateral Episcleritis Without Red Flags
No routine laboratory workup is required if the patient has:
- Mild symptoms only
- No systemic symptoms
- First episode
- Clear clinical diagnosis 1
When to Pursue Systemic Workup
Order targeted investigations when:
- Recurrent episodes occur 5
- Bilateral involvement is present 5
- Systemic symptoms are present 6
- Nodular episcleritis (more likely systemic association) 1
- Patient has known autoimmune disease 6
Specific Laboratory Tests to Consider
When systemic disease is suspected:
- Complete blood count (hematologic involvement in autoimmune disease) 6
- Inflammatory markers: ESR, CRP (disease activity) 6
- Autoimmune serologies: ANA, RF, anti-CCP (for RA), ANCA (for vasculitis) 4, 6
- Anti-dsDNA and complement levels if SLE suspected 6
- Stool studies and colonoscopy referral if IBD symptoms present 3
Ophthalmology Referral Indications
Simple episcleritis does not require ophthalmology referral if diagnosis is clear and symptoms are mild 1
Refer urgently if:
- Any suspicion of scleritis (severe pain, deep injection, vision changes) 1
- No improvement after 2-4 weeks of topical therapy 1
- Visual disturbance, photophobia, or moderate-to-severe pain develop 3
- Ocular complications suspected (uveitis, corneal involvement, glaucoma can occur in 11-34% of cases) 5
Common Pitfalls to Avoid
- Do not mistake scleritis for episcleritis: severe pain should immediately raise concern for scleritis, which requires systemic treatment 1, 7
- Do not perform extensive autoimmune workup on every patient: reserve for those with systemic symptoms or recurrent disease 5
- Do not ignore underlying disease activity: episcleritis often reflects inadequate control of systemic conditions like RA or IBD 1
- Do not trivialize the condition: despite being generally benign, 36% have associated systemic disease and complications can occur 5
- Perform annual review of systems during follow-up: systemic disease can emerge later (episcleritis preceded systemic vasculitis in documented cases) 5