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Episcleritis

BASICS

DESCRIPTION

  • Inflammation and irritation of the episclera, thin vascular connective tissue between conjunctiva and sclera.
  • Typically benign and self-limited, resolves within 3 weeks without treatment.
  • Symptoms may be relieved with topical lubricants and/or corticosteroids.

TYPES

  • Simple episcleritis: diffuse scleral involvement, more common.
  • Nodular episcleritis: focal area(s) of involvement, less common.

EPIDEMIOLOGY

  • Slight female predominance (~60-65%).
  • Can occur at any age; peak incidence 40s-50s.
  • Incidence ~20-50 cases per 100,000 person-years.
  • Prevalence ~53 cases per 100,000 person-years in recent study.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Usually idiopathic; ~1/3 have systemic autoimmune disease.
  • Pathophysiology:
  • Nonimmune: dry eye syndrome, vasodilation, edema, lymphocytic infiltration.
  • Immune: systemic vasculitis, rheumatologic disease.

COMMONLY ASSOCIATED CONDITIONS

  • Usually isolated, but can be early sign of systemic disease such as:
  • Rheumatoid arthritis
  • Vasculitis
  • Inflammatory bowel disease
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Systemic lupus erythematosus
  • Gout
  • Herpes zoster
  • Hypersensitivity disorders
  • Rosacea
  • Contact dermatitis
  • Penicillin sensitivity
  • Erythema multiforme
  • Can be ocular manifestation of infectious conditions.

DIAGNOSIS

CLINICAL DIAGNOSIS

  • Episcleritis diagnosed clinically.

PHENYLEPHRINE TEST

  • 10% phenylephrine eye drops used to distinguish from scleritis.
  • Blanching = episcleritis (superficial vessels).
  • No blanching = scleritis (deeper vessels).

HISTORY

  • Assess for causative factors, recurrence, systemic disease.
  • Pain: usually absent or mild, localized.
  • Mild tearing possible.

PHYSICAL EXAM

  • Visual acuity usually normal; decreased vision suggests other diagnosis (e.g., scleritis).
  • Pink or purplish sclera due to superficial episcleral vascular dilation.
  • Focal hyperemia and episcleral edema (diffuse in simple, focal in nodular).
  • Pupils equal, reactive.
  • Tenderness over involved area may be present but usually absent.
  • Episcleral hyperemia blanches with phenylephrine.

Alert: Recurrent, diagnostic uncertainty, or worsening symptoms require ophthalmology referral.

DIFFERENTIAL DIAGNOSIS

  • Scleritis
  • Bacterial/viral conjunctivitis
  • Uveitis
  • Herpes (ulcerative) keratitis
  • Superficial keratitis
  • Ocular hypertension

DIAGNOSTIC TESTS

  • Extensive labs usually unnecessary unless suspicion for scleritis or refractory disease.
  • Possible labs: CBC, CMP, ESR, CRP, RF, ANA, ANCA, complements, RPR, HLA B27, ACE, urinalysis.
  • TB screening (PPD or T-SPOT).
  • Imaging: chest X-ray, chest CT if systemic disease suspected.

TREATMENT

GENERAL

  • Simple episcleritis self-limited (up to 21 days).
  • Nodular form may be prolonged, painful.

MEDICATION

First Line

  • Topical lubricants/artificial tears.

Second Line

  • Topical NSAIDs (Diclofenac 0.1%, Ketorolac 0.5%).
  • Topical corticosteroids (Fluorometholone, Prednisolone 0.5-1%).
  • Oral NSAIDs or COX inhibitors for refractory cases.

ISSUES FOR REFERRAL

  • Ophthalmology referral if:
  • Corticosteroid eye drops needed
  • Recurrent episodes
  • Diagnostic uncertainty
  • Worsening symptoms
  • Suspected progression to scleritis

ADDITIONAL THERAPIES

  • Topical NSAIDs not superior to artificial tears.
  • Antiviral therapy if viral cause identified.

ONGOING CARE

FOLLOW-UP

  • Usually none needed; self-limited condition.

PROGNOSIS

  • Full recovery typical without complications.

COMPLICATIONS

  • Rare.
  • Anterior uveitis (4-16%).
  • Decreased vision (0-4%).
  • Ocular hypertension (0-3.5%).

REFERENCES

  1. Diaz JD, Sobol EK, Gritz DC. Treatment and management of scleral disorders. Surv Ophthalmol. 2016;61(6):702-717.
  2. Miller JR, Hanumunthadu D. Inflammatory eye disease: clinical overview. Clin Med (Lond). 2022;22(2):100-103.

CODES

  • ICD10 H15.109 Unspecified episcleritis, unspecified eye
  • ICD10 H15.129 Nodular episcleritis, unspecified eye
  • ICD10 H15.102 Unspecified episcleritis, left eye

CLINICAL PEARLS

  • Episcleritis is inflammation of the thin vascular layer between conjunctiva and sclera.
  • Usually benign, self-limited, resolving within 3 weeks.
  • Mild or no pain; vision usually unaffected.
  • Treatment aims at symptom relief pending spontaneous resolution.
  • Differentiate from scleritis using phenylephrine test.
  • Referral required if recurrent, worsening, or uncertain diagnosis.
  • Complications uncommon but include anterior uveitis and ocular hypertension.