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Ophthalmology – Episcleritis
Episcleritis is a benign, self-limited inflammatory condition affecting the episclera, the thin vascular layer just beneath the conjunctiva. It is typically mild, though it may be recurrent, and most commonly affects young adults, with a higher prevalence in females. Up to 30% of cases are associated with an underlying systemic condition.
There are two main clinical forms. Simple episcleritis presents with intermittent episodes of redness that resolve within 2–3 weeks. Nodular episcleritis is less common but tends to be more painful, prolonged, and characterized by a localized, raised inflammatory nodule. This form is more frequently associated with systemic disease.
The exact pathophysiology is not fully understood but is believed to involve a localized inflammatory response to an inciting trigger. The etiology is often idiopathic, though it may be associated with collagen vascular diseases (such as rheumatoid arthritis or lupus), infections (e.g., Lyme disease or syphilis), and other systemic conditions like gout or rosacea. Stress and hormonal changes have also been implicated.
Patients typically present with acute onset of redness, mild irritation, and tearing, often in a sectoral (localized) or diffuse pattern. Unlike more severe inflammatory conditions, pain is usually mild or absent, and vision is typically unaffected.
On examination, there is sectoral or diffuse conjunctival/episcleral injection, sometimes with a mobile, localized nodule. A key distinguishing feature is that the inflamed area can be moved over the sclera with a cotton-tipped applicator after topical anesthesia. Additionally, instillation of 2.5% phenylephrine drops causes blanching of the superficial vessels, helping differentiate episcleritis from deeper conditions like scleritis. About 10% of patients may have associated anterior uveitis, so a careful anterior segment exam is important.
Diagnosis is primarily clinical. Laboratory testing is not routinely required for isolated cases but should be considered in recurrent, severe, or nodular episcleritis, especially if systemic disease is suspected. Workup may include CBC, ESR, ANA, rheumatoid factor, uric acid levels, chest X-ray, and syphilis testing (VDRL, FTA-ABS).
The differential diagnosis includes conjunctivitis, scleritis (which is more painful and does not blanch with phenylephrine), and pingueculitis.
Management is usually conservative. First-line treatment includes artificial tears and cool compresses, which are often sufficient due to the self-limiting nature of the condition. For symptomatic relief, topical antihistamines or NSAIDs may be used. In more moderate cases, oral NSAIDs (e.g., indomethacin) or a short course of topical corticosteroids may be prescribed.
Follow-up is generally not required for isolated cases but is recommended for recurrent episodes or atypical presentations. Referral to an ophthalmologist is advised if there are corneal changes, persistent symptoms, or suspicion of underlying systemic disease.
The prognosis is excellent, with most cases resolving without complications. However, recurrence is common, and identifying any associated systemic condition is important for long-term management.
Episcleritis is a benign, self-limited inflammatory condition affecting the episclera, the thin vascular layer just beneath the conjunctiva. It is typically mild, though it may be recurrent, and most commonly affects young adults, with a higher prevalence in females. Up to 30% of cases are associated with an underlying systemic condition.
There are two main clinical forms. Simple episcleritis presents with intermittent episodes of redness that resolve within 2–3 weeks. Nodular episcleritis is less common but tends to be more painful, prolonged, and characterized by a localized, raised inflammatory nodule. This form is more frequently associated with systemic disease.
The exact pathophysiology is not fully understood but is believed to involve a localized inflammatory response to an inciting trigger. The etiology is often idiopathic, though it may be associated with collagen vascular diseases (such as rheumatoid arthritis or lupus), infections (e.g., Lyme disease or syphilis), and other systemic conditions like gout or rosacea. Stress and hormonal changes have also been implicated.
Patients typically present with acute onset of redness, mild irritation, and tearing, often in a sectoral (localized) or diffuse pattern. Unlike more severe inflammatory conditions, pain is usually mild or absent, and vision is typically unaffected.
On examination, there is sectoral or diffuse conjunctival/episcleral injection, sometimes with a mobile, localized nodule. A key distinguishing feature is that the inflamed area can be moved over the sclera with a cotton-tipped applicator after topical anesthesia. Additionally, instillation of 2.5% phenylephrine drops causes blanching of the superficial vessels, helping differentiate episcleritis from deeper conditions like scleritis. About 10% of patients may have associated anterior uveitis, so a careful anterior segment exam is important.
Diagnosis is primarily clinical. Laboratory testing is not routinely required for isolated cases but should be considered in recurrent, severe, or nodular episcleritis, especially if systemic disease is suspected. Workup may include CBC, ESR, ANA, rheumatoid factor, uric acid levels, chest X-ray, and syphilis testing (VDRL, FTA-ABS).
The differential diagnosis includes conjunctivitis, scleritis (which is more painful and does not blanch with phenylephrine), and pingueculitis.
Management is usually conservative. First-line treatment includes artificial tears and cool compresses, which are often sufficient due to the self-limiting nature of the condition. For symptomatic relief, topical antihistamines or NSAIDs may be used. In more moderate cases, oral NSAIDs (e.g., indomethacin) or a short course of topical corticosteroids may be prescribed.
Follow-up is generally not required for isolated cases but is recommended for recurrent episodes or atypical presentations. Referral to an ophthalmologist is advised if there are corneal changes, persistent symptoms, or suspicion of underlying systemic disease.
The prognosis is excellent, with most cases resolving without complications. However, recurrence is common, and identifying any associated systemic condition is important for long-term management.
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