In a healthy 15‑year‑old with acute unilateral sectoral episcleritis causing mild pain and scleral redness for a few hours, what is the drug of choice and initial management?

Management of Acute Unilateral Episcleritis in a 15-Year-Old

For this adolescent with simple episcleritis (mild pain, sectoral scleral redness, preserved vision, no photophobia), start with artificial tears for symptomatic relief and observe—no ophthalmology referral is needed unless symptoms worsen or fail to improve within 2-4 weeks. 1, 2

Confirming the Diagnosis

The clinical presentation strongly suggests simple episcleritis rather than more serious conditions:

• Mild pain only (not moderate-to-severe) rules out scleritis, which causes severe, deep ocular pain 1, 2, 3
• No photophobia, no visual disturbance, no blurred vision excludes uveitis and scleritis 1, 2, 4
• Normal eyelid with only superficial scleral/episcleral hyperemia is characteristic of episcleritis 1, 5
• Acute onset over hours in a previously healthy adolescent fits the typical presentation 5

Initial Management: Conservative Approach

First-line treatment for simple episcleritis:

• Artificial tears (lubricating drops) provide symptomatic relief and are the initial recommendation 1, 2, 3
• Cold compresses can help reduce discomfort 5
• Observation is appropriate as most cases are self-limiting and resolve within 1-3 months 5, 3

No ophthalmology referral is required for simple episcleritis when the diagnosis is clear and there are no red flags 1, 2

When to Escalate Treatment

Add topical NSAIDs or topical corticosteroids only if symptoms persist beyond initial conservative management:

• Topical NSAIDs (e.g., ketorolac, diclofenac) are effective for persistent symptoms 1, 4, 5
• Topical corticosteroids (e.g., prednisolone acetate 1%) can be used if NSAIDs are insufficient 1, 4
• Coordinate with ophthalmology if initiating topical steroids, as starting steroids before proper examination can mask infectious causes like herpetic keratitis 1

Red Flags Requiring Urgent Ophthalmology Referral

Immediately refer to ophthalmology if any of these develop:

• Moderate-to-severe pain suggests scleritis, not episcleritis 1, 2, 4
• Visual disturbance or blurred vision indicates possible uveitis or scleritis 1, 2, 4
• Photophobia suggests intraocular inflammation (uveitis) 1, 2, 4
• No improvement after 2-4 weeks of topical therapy warrants slit-lamp examination 2, 6
• Worsening symptoms despite treatment requires diagnostic reassessment 2

Systemic Workup Considerations

For this isolated, first episode in a healthy adolescent, no laboratory workup is needed initially 2:

• Most episcleritis cases are idiopathic, especially in young patients 7, 5, 3
• Systemic associations (inflammatory bowel disease, rheumatoid arthritis) are more common in adults and with recurrent episodes 1, 2, 7
• Screen for systemic symptoms: Ask about diarrhea, bloody stools, abdominal pain (IBD), or joint pain/morning stiffness (rheumatoid arthritis) 2, 4
• If systemic symptoms are present or episcleritis recurs, targeted workup for autoimmune disease is warranted 2, 7

Follow-Up Strategy

• Reassess in 48-72 hours to ensure symptoms are improving 6
• If no improvement by 2-4 weeks, refer to ophthalmology for slit-lamp examination to rule out scleritis or other diagnoses 2, 6
• Annual systemic review is recommended for recurrent cases, as episcleritis may precede diagnosis of systemic vasculitic diseases 2

Critical Pitfalls to Avoid

• Do not confuse episcleritis with scleritis: Severe pain immediately signals scleritis, which requires urgent systemic treatment to prevent vision loss 1, 2, 8, 3
• Do not start topical steroids without ruling out infection: Herpetic keratitis can be worsened by steroids 1
• Do not delay ophthalmology referral if any red flags develop—scleritis and uveitis can progress rapidly 1, 2, 4