Treatment Plan

How to Treat Episcleritis

BY WILLIAM L. MILLER, OD, PHD, FAAO

Recently, I treated an episode of episcleritis in a patient who has Crohn’s disease. This case brought to mind other systemic diseases that can affect the ocular surface and anterior segment—sometimes overlooked as the basis for what we see with the slit lamp.

Differential diagnoses for episcleritis include superior limbic keratoconjunctivitis (location is the key differentiator), viral conjunctivitis (look for lymphadenopathy and generalized conjunctival hyperemia), and scleritis. Differentiating the latter is the most crucial as the associated morbidity is much higher.

Nearly 70% of patients who have episcleritis are female; most cases (80%) are simple, the rest nodular. Nodular episcleritis cases are more resistant to treatment, take longer to resolve, and have a greater propensity for ocular irritation and mild pain. Although both simple and nodular episcleritis (Figure 1) exhibit sectoral redness, the raised and nodular appearance is the key to diagnosis.

Figure 1. Resolving nodular episcleritis.

Episcleritis occurs in 26% to 36% of patients who have systemic disease (Watson and Hayreh, 1976; Sainz de la Maza et al, 1994; Akpek et al, 1999; Sainz de la Maza et al, 2012), including inflammatory and collagen vascular diseases as well as vasculitic (Behçet’s disease) and dermatologic (rosacea). Other causes include infections (herpes simplex and zoster as well as chlamydia), foreign body, and systemic medications.

Treatment Options

Very mild cases are often self-limiting and can be handled with tear supplements (can be refrigerated in the acute phase of the disease) and cold compress. In a study by Jabs et al (2000), nearly 17% of episcleritis patients did not require treatment. Contact lens wear should be halted until the condition resolves.

In moderate-to-severe cases, especially in nodular episcleritis, therapeutic intervention is necessary. Corticosteroids, including fluorometholone, loteprednol, and prednisolone, remain the most commonly used topical medication. Prednisolone can be reserved for more severe forms of the condition. A loteprednol gel or ointment may be useful for those patients who are unable to discontinue lens wear because it can be dosed once a day at bedtime. Typical caution should be adhered to regarding glaucoma and cataracts; however, the duration of drug usage in episcleritis is typically less than a week and in many cases is just a few days. It is best to be aggressive initially with a very quick taper over a few days.

Other ophthalmic medications may include topical nonsteroidal anti-inflammatory drugs (NSAIDs), such as bromfenac, diclofenac, and flurbiprofen, given q.d. or b.i.d. with added dosing depending on severity. Oral NSAIDs may also be used in cases of severe and/or indolent cases of episcleritis.

Even in mild forms of the condition, ibuprofen or naproxen sodium (200mg b.i.d.) can relieve symptoms (Akpek et al, 1999). In rare cases, prescription forms for more severe episcleritis may include indomethacin (25mg t.i.d.) and flurbiprofen (50mg to 100mg b.i.d. or t.i.d.). Most of the oral medications are typically reserved for scleritis and rarely for episcleritis. However, some of these medications would be contraindicated based on the underlying systemic disease. In such cases, COX-2 inhibitors, such as celecoxib, can be useful. CLS

For references, please visit www.clspectrum.com/references and click on document #240.

Dr. Miller is an associate dean for academic affairs and professor at the Rosenberg School of Optometry, University of the Incarnate Word. He is a consultant or advisor to Alcon and Oasis Medical and has received research funding from CooperVision, Contamac, and SynergEyes and lecture or authorship honoraria from Alcon. You can reach him at wlmiller@uiwtx.edu.