Treatment of Simple Sectoral Episcleritis in a Healthy 15-Year-Old
For simple sectoral episcleritis in an otherwise healthy adolescent, start with preservative-free artificial tears every 2-4 hours, and if symptoms persist beyond 2-3 days or are significantly bothersome, add topical corticosteroids (prednisolone acetate 1%) four times daily for 1-2 weeks with gradual taper. 1, 2, 3
Initial Management Approach
Begin with conservative symptomatic treatment using preservative-free artificial tears every 2-4 hours during the acute phase, as episcleritis is typically a self-limited condition that resolves within 2-3 weeks without aggressive intervention 1, 2, 4
Cold compresses can be added for additional symptomatic relief in conjunction with artificial tears 4
Simple episcleritis does not require ophthalmology referral if the diagnosis is clear and symptoms are mild, though reassessment is warranted if no improvement occurs 1
When to Escalate to Topical Corticosteroids
If symptoms persist beyond 2-3 days or are causing significant discomfort, add topical prednisolone acetate 1% (Pred Forte) four times daily 3, 5, 6
The typical treatment course is 1-2 weeks followed by gradual taper over several weeks to prevent rebound inflammation 3, 5
Prednisolone acetate should be dosed as two drops in the affected eye four times daily, with care taken not to discontinue therapy prematurely 3
If signs and symptoms fail to improve after two days of topical steroid therapy, the patient should be reevaluated 3
Alternative Options for Persistent Cases
Topical NSAIDs can be considered as an alternative or adjunct to topical corticosteroids for persistent symptoms, particularly in patients where steroid use is a concern 1, 4, 5
Oral NSAIDs at the minimum effective dose may be used for recalcitrant cases, though this is rarely necessary in simple episcleritis 7, 4
Critical Differential Diagnosis Considerations
The presence of severe pain should immediately raise concern for scleritis rather than episcleritis, which would require urgent ophthalmology referral and systemic treatment 8, 1, 5
Episcleritis presents with mild discomfort, redness, and lacrimation, while scleritis causes severe, boring pain that may radiate and is associated with deep vessel injection 8, 5, 9
Any vision changes, severe pain, or deep injection pattern mandates urgent ophthalmology consultation to rule out scleritis 8, 1
Monitoring and Follow-Up
Reassess within 2-4 weeks if symptoms persist despite topical therapy, as this may indicate nodular episcleritis (which tends to be more recurrent and painful) or an alternative diagnosis 1, 4
The nodular form of episcleritis is more likely to recur and may require longer treatment courses 1, 4
In a healthy 15-year-old with simple sectoral episcleritis, systemic workup for rheumatologic disease is not indicated unless there are recurrent episodes or systemic symptoms 4, 5
Common Pitfalls to Avoid
Do not use preserved artificial tears for frequent application (more than 4 times daily), as preservative toxicity can worsen ocular surface irritation 2
Do not mistake scleritis for episcleritis - severe pain is the key distinguishing feature that demands immediate escalation of care 8, 1
Do not use systemic immunosuppression for simple episcleritis - topical therapy is sufficient in uncomplicated cases 1
Avoid prolonged topical corticosteroid use without tapering, as this increases risk of elevated intraocular pressure and other steroid-related complications 2, 3