Episcleritis

Episcleritis is a benign, self-limiting inflammatory disease affecting part of the eye called the episclera. The episclera is a thin layer of tissue that lies between the conjunctiva and the connective tissue layer that forms the white of the eye (sclera). Episcleritis is a common condition, and is characterized by the abrupt onset of painless eye redness.

Episcleritis
Eye with Episcleritis
SpecialtyOphthalmology
SymptomsEye redness without pain
Watery eyes
TypesNodular and simple/diffuse
Diagnostic methodHistory and physical examination
Differential diagnosisScleritis
TreatmentArtificial tears, supportive care
MedicationTopical corticosteroids
Non-steroidal anti-inflammatory drugs.
PrognosisGood

There are two types of episcleritis, nodular and simple. Nodular episcleritis lesions have raised surface. Simple episcleritis lesions are flat. There are two subtypes. In diffuse simple episcleritis, inflammation is generalized. In sectoral simple episcleritis, the inflammation is restricted to one region.

Most cases of episcleritis have no identifiable cause, although about a third of cases are associated with various systemic diseases. Often people with episcleritis experience it recurrently. Treatment focuses on decreasing discomfort, and includes lubricating eye drops. More severe cases may be treated with topical corticosteroids or oral anti-inflammatory medications (NSAIDs).

Signs and symptoms
Episcleritis of a 40 years old female

Symptoms of episcleritis typically include painless redness of the eye (mild pain is possible but atypical), and watery eyes.[1] The pain of episcleritis is typically mild, less severe than in scleritis,[2] and may be tender to palpation.[3]

There are two types of episcleritis: the diffuse type, where the redness involves the entire episclera, and the nodular type, where the redness appears more nodular, involving only a small, well-circumscribed area (sectoral).[4] The diffuse type of episcleritis may be less painful than the nodular type. Sometimes, small nodules are present within the episclera, which move slightly over the sclera with gentle pressure.[4]

Discharge is absent with episcleritis, and vision is unaffected.[4] Patients with episcleritis experience far less photophobia than patients with uveitis.[1] Episcleritis does not cause the presence of cells or flare in the anterior chamber of the eye.[1] In 80 percent of cases, episcleritis affects only one eye,[5] whereas scleritis often affects both eyes.

Pathophysiology

Episcleritis is caused by inflammation due to the activation of immune cells, including lymphocytes and macrophages.[5] Most of the time, the cause of episcleritis is never determined (idiopathic). An identifiable cause is discovered in about one third of cases.[6] Several diseases are associated with episcleritis, including systemic vasculitis (polyarteritis nodosa, granulomatosis with polyangiitis, Behçet's disease), connective tissue diseases (rheumatoid arthritis, relapsing polychondritis, systemic lupus erythematosus),[7] psoriatic arthritis, ankylosing spondylitis, Cogan syndrome, rosacea, gout,[4] atopy,[6] Crohn's disease, and ulcerative colitis.[8][5] 59 percent of patients with relapsing polychondritis have either episcleritis or scleritis.[9] Rarely, episcleritis may be caused by scleritis.[10] Very rarely, episcleritis is associated with infections, including Lyme disease, tuberculosis, syphilis, and herpes zoster.[5]

The redness in the eye associated with episcleritis is due to engorgement of the large episcleral blood vessels, which run in a radial direction from the limbus.[4] Typically, there is no uveitis, or thickening of the sclera.

Diagnosis

The diagnosis of episcleritis is based upon the history and physical examination. The history should be explored for the presence of the diseases associated with episcleritis, and the symptoms they cause, such as rash, arthritis, venereal disease, and recent viral infection.[4] Episcleritis may be differentiated from scleritis by using phenylephrine or neosynephrine eye drops, which causes blanching of the blood vessels in episcleritis, but not in scleritis.[2] A blue color to the sclera suggests scleritis, rather than episcleritis. After anesthetizing the eye with medication, the conjunctiva may be moved with a cotton swab to observe the location of the enlarged blood vessels.

In very rare cases, if episcleritis does not respond to treatment, then a biopsy may be considered,[5] which help provide information regarding any underlying condition (granulomatosis with polyangitis, vasculitis, etc.). However, a biopsy is not routinely necessary in the diagnosis of episcleritis.

Treatment

Often, treatment is not necessary, because episcleritis is a self-limiting condition. Artificial tears may be used to help with irritation and discomfort. More severe cases can be treated with either topical corticosteroids or oral non-steroidal anti-inflammatory drugs.[6]

Ketorolac, a topical NSAID, may be used, but it is not more effective than artificial tears and it causes more side effects.[11]

Prognosis

Episcleritis is a benign, self-limiting condition, meaning patients recover without any treatment. Most cases of episcleritis resolve within 7–10 days.[1] The nodular type is more aggressive and takes longer to resolve.[1] Although rare, some cases may progress to scleritis.[12] However, in general, episcleritis does not cause complications in the eye.[12] Smoking tobacco delays the response to treatment in patients with episcleritis.[13]

Epidemiology

While episcleritis is a common disease,[14] its exact prevalence and incidence are unknown.[5] It typically affects young[14] or middle aged women.[5] The diffuse form of episcleritis (70%) is more common than the nodular form (30%).[5] One retrospective study found 28 percent of individuals with episcleritis experienced recurrent episodes of the disease.[15]

References
  1. Heath, Greg (10 February 2010). "The episclera, sclera and conjunctiva An overview of relevant ocular anatomy" (PDF). OT: 36–42. Archived from the original (PDF) on 13 May 2013. Retrieved 30 November 2012.
  2. Goldman, Lee (2011). Goldman's Cecil Medicine (24th ed.). Philadelphia: Elsevier Saunders. pp. 2440. ISBN 978-1437727883.
  3. Chumley H; Usatine RP; Smith MA; Chumley H; Mayeaux Jr. E; Tysinger J (2009). The Color Atlas of Family Medicine: Chapter 16. Scleritis and Episcleritis (2nd ed.). New York: McGraw-Hill Education Medical. ISBN 978-0071769648.
  4. Kunimoto, Derek; Kunal Kanitkar; Mary Makar (2004). The Wills eye manual: office and emergency room diagnosis and treatment of eye disease (4 ed.). Philadelphia, PA: Lippincott Williams & Wilkins. pp. 99–100. ISBN 978-0781742078.
  5. Schonberg, S; Stokkermans, TJ (January 2020). "Episcleritis". PMID 30521217. Cite journal requires |journal= (help)
  6. Yanoff, Myron; Jay S. Duker (2008). Ophthalmology (3rd ed.). Edinburgh: Mosby. pp. 255–261. ISBN 978-0323057516.
  7. Watson, PG; Hayreh, SS (March 1976). "Scleritis and episcleritis". The British Journal of Ophthalmology. 60 (3): 163–91. doi:10.1136/bjo.60.3.163. PMC 1042706. PMID 1268179.
  8. Langholz, E. (March 2010). "Review: Current trends in inflammatory bowel disease: the natural history". Therapeutic Advances in Gastroenterology. 3 (2): 77–86. doi:10.1177/1756283X10361304. PMC 3002570. PMID 21180592.
  9. Sabatine, Marc S. (2011). Pocket Medicine (4th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 8–4. ISBN 978-1608319053.
  10. "Episcleritis: MedlinePlus Medical Encyclopedia". Bethesda, MD: United States National Library of Medicine. Retrieved 20 June 2010.
  11. Williams, CP; Browning, AC; Sleep, TJ; Webber, SK; McGill, JI (July 2005). "A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis". Eye (London, England). 19 (7): 739–42. doi:10.1038/sj.eye.6701632. PMID 15359265.
  12. Jabs, Douglas A.; Mudun, Abdulbaki; Dunn, J.P.; Marsh, Marta J. (Oct 2000). "Episcleritis and scleritis: clinical features and treatment results". American Journal of Ophthalmology. 130 (4): 469–476. doi:10.1016/S0002-9394(00)00710-8. PMID 11024419.
  13. Boonman, Z F H M; de Keizer, R J W; Watson, P G (September 2005). "Smoking delays the response to treatment in episcleritis and scleritis". Eye. 19 (9): 949–955. doi:10.1038/sj.eye.6701731. PMID 15543188.
  14. Levsky M.E.; DeFlorio P. (2010). Atlas of emergency medicine: Chapter 2 Ophthalmologic Conditions (3rd ed.). New York: McGraw-Hill Professional. ISBN 978-0071496186.
  15. Akpek, EK; Uy, HS; Christen, W; Gurdal, C; Foster, CS (April 1999). "Severity of episcleritis and systemic disease association". Ophthalmology. 106 (4): 729–31. doi:10.1016/S0161-6420(99)90157-4. PMID 10201593.
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