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Episcleritis

Episcleritides


Presentation

Episcleritis presents with the following signs and symptoms:

Relapsing Polychondritis
  • Causes of scleritis: Systemic autoimmune diseases such as rheumatoid arthritis, Wegener granulomatosis, seronegative spondyloarthropathies, relapsing polychondritis, systemic lupus erythematosus (SLE).[accessmedicine.mhmedical.com]
  • polychondritis have either episcleritis or scleritis.[8] Rarely, episcleritis may be caused by scleritis.[9] The redness in the eye associated with episcleritis is due to engorgement of the large episcleral blood vessels, which run in a radial direction[en.wikipedia.org]
  • Fifty-nine percent of people with relapsing polychondritis, which is the deterioration and inflammation of cartilage, have either scleritis or episcleritis. It is very rare for scleritis to cause episcleritis.[healthool.com]
Disability
  • Especially since early treatment results in complete elimination of Treponema pallidum, thus preventing disabilities and neurological deterioration as a consequence of late stage infection.[ncbi.nlm.nih.gov]
  • I have had to retire from my beautiful profession, and I have just been granted full SS disability. I am 56 yrs old. So, most of my days are spent with assessment of my pain, managing my pain, and in bed, with few trips to the store, etc.[tapatalk.com]
Periodontitis
  • Tobacco and smoking: environmental factors that modify the host response (immune system) and have an impact on periodontal health. Crit Rev Oral Biol Med 1997; 8 : 437–460. 32 Albano SA, Santana-Sahagun E, Weisman MH.[doi.org]
Alopecia
  • Common side effects include acneiform (papulopustular) rash, diarrhea, edema, pruritus, dry skin and alopecia.[ncbi.nlm.nih.gov]
Keratosis
  • Abstract Keratosis follicularis (Darier's disease) is an autosomal dominant dermatological disorder characterised by abnormal epidermal differentiation and loss of normal cell-to-cell adhesion.[ncbi.nlm.nih.gov]
Red Eye
  • Raphael Rosenbaum Scleritis or Episcleritis Which Red Eye is it?. . Patients often come to my office complaining of having episodic red blood shot eyes.[eyesurgeonsnyc.com]
  • The red eyes were, therefore, manifestation of the sinusitis. He was treated systemically with penicillin and non-steroidal spray and the ocular lesions disappeared as a result of this therapy.[ncbi.nlm.nih.gov]
  • If you are really bothered by your red eyes, it is best to see a doctor for proper medical intervention.[getholistichealth.com]
  • Red eye. BMJ. 2005; 331(7514): 438. (3) Smith JR. Therapy Insight: scleritis and its relationship to systemic autoimmune disease. Nature Clin Pract Rheumatol. 2007; 3: 219-226 Links: management scleritis[gpnotebook.co.uk]
Miosis
  • Topical 0.5% ketorolac vs 0.03% flurbiprofen for inhibition of miosis during cataract surgery. Arch Ophthalmol 1997; 115 : 1119–1122. 13 Kaiser PK, Pineda R.[dx.doi.org]
  • Topical 0.5% ketorolac vs 0.03% flurbiprofen for inhibition of miosis during cataract surgery. Arch Ophthalmol 1997; 115 : 1119–1122. 13. Kaiser PK, Pineda R.[nature.com]
Diplopia
  • A 53-year-old patient presented with recurrent epicleritis of the right eye for 6 months and progressive diplopia. He had a past history of orbital floor repair over 30 years.[ncbi.nlm.nih.gov]
  • SCLERITIS • Patients may complain of loss of vision, pain, or diplopia and findings may include hyperopia, conjunctival chemosis, proptosis, lid edema or retraction, and ophthalmoplegia • Posterior segments optic nerve edema, optic neuritis, serous and[slideshare.net]
Intracranial Hemorrhage
  • Intravenous methylprednisolone (1 g/day) was started; however, the patient succumbed 10 days later after intracranial hemorrhage.[ncbi.nlm.nih.gov]

Workup

A thorough physical examination of the eye to study the signs and symptoms of episcleritis will be done. Physical examination will be enough to diagnose the condition. However, if the condition keeps recurring after intermittent intervals then blood test would be required to diagnose the presence of any underlying disease condition. Apart from these, no specialized tests are necessary to diagnose episcleritis.

HLA-DR4
  • The frequency of HLA-DR4 was significantly decreased among the patients with episcleritis (15.2%) compared to patients without episcleritis (39.1%; odds ratio 0.28, P 0.05) and the controls (46.5%; odds ratio 0.21, P 0.001).[ncbi.nlm.nih.gov]
Lymph Node Biopsy showing Reed-Sternberg Cells
  • A cervical lymph node biopsy showed Reed-Sternberg cells and a chronic lymphocytic infiltrate consistent with nodular sclerosing Hodgkin's lymphoma. Histopathologic analysis of an episcleral nodule revealed a necrotizing granuloma with vasculitis.[ncbi.nlm.nih.gov]

Treatment

In majority of the cases, episcleritis gets resolved on its own and does not require any specialized treatment plan. However, if the inflammation is severe and the patient is in great discomfort then certain eye drops may be administered to provide quick relief.

The goal of pharmacotherapy in the treatment of episcleritis is to reduce relative morbidity and avert complications [8]. Generally corticosteroid eye drops that act as artificial tears are prescribed for relieving the signs and symptoms of episcleritis [9]. The use of oral cyclooxygenase inhibitors has been found to effectively reduce signs of inflammation in episcleritis [10].

For patients with nodular episcleritis, a more rigorous treatment regime may be required due to development of severe signs and symptoms. Non–steroidal anti–inflammatory drugs are useful in relieving symptoms of nodular episcleritis.

In patients with underlying disease conditions, treatment is also initiated to keep the disease condition under control. This would help to prevent recurrent bouts of episcleritis.

Prognosis

The prognosis of the disease condition is favorable and symptoms often fade away by themselves without any treatment [6]. However, with treatment symptoms resolve sooner and patients can recover faster.

Complications

Episcleritis is not a life threatening condition and gets better without any treatment regime. However, in rare cases the condition can give rise to some kind of complications. Current literature has suggested that episcleritis can give rise to scleritis which is characterized by inflammation and irritation accompanied by redness of the sclera of the eyes.

Complications can develop in those individuals who have suffered from recurrent attacks of episcleritis and had to resort to steroid treatment for several years. In such cases, the following secondary complications can develop:

Etiology

The exact cause that triggers inflammation and redness of the episclera region of the eyes is yet to be known. However, in many cases it is thought to occur as a secondary complication to many disease conditions [3]. Episcleritis occurs in association with the following medical conditions:

Epidemiology

Episcleritis is an inflammatory disease of the eyes, more commonly affecting the young and middle aged population. It has been estimated that about 70% of women are affected with this condition [5]. The exact prevalence rate of this disease is not available as most of the patients do not seek any medical help.

Sex distribution
Age distribution

Pathophysiology

Episcleritis is of two types: Simple and nodular. Simple episcleritis is more common that nodular and is less severe and painful. The following are the characteristics of simple episcleritis:

  • Recurrent intermittent bouts that occur at every 1 – 3 months intervals. The condition lasts for as long as 7 to 10 days. 
  • Patients who suffer from simple episcleritis as a secondary result to other underlying condition, often experience more severe symptoms and the condition takes more than normal time to heal.
  • When episcleritis occurs spontaneously and not as a result of any underlying condition then hormonal changes and stress are known to trigger the development of this eye disease.

Nodular episcleritis is a more severe form than the former type. The attacks are more painful, severe and last longer. Individuals with nodular episcleritis always have an underlying systemic disease which is the major causative factor.

Prevention

So far no guidelines have been given for preventing the onset of episcleritis. The onset of complications can be prevented by timely treatment of the condition and also by proper management of the underlying disease conditions.

Summary

Episcleritis is a condition characterized by inflammation and redness of the episclera. The episclera is a thin tissue layer situated between the conjunctiva and sclera [1]. The redness and inflammation of the eyes mimic the signs and symptoms of conjunctivitis; however, in episcleritis there is no discharge from the eyes. It is a common condition affecting several individuals across the globe. The cause of such a condition is not known in many cases.

Episcleritis is a mild condition and often usually resolves by itself requiring no rigorous treatment regime [2]. Women are more affected than men and it strikes both middle aged and young individuals.

Patient Information

Definition

Episcleritis presents with redness and inflammation of the episclera region of the eyes. Infection is not the cause of episcleritis and the condition either occurs spontaneously or due to certain underlying conditions. Middle aged women are at an increased risk of contracting this disease condition.

Cause

The exact cause that triggers the development of episcleritis is unknown. However, individuals with disease such as herpes zoster, tuberculosis, rheumatoid arthritis, syphilis and Sjogren syndrome are known to develop this eye condition.

Symptoms

Symptoms of episcleritis include inflammation and redness in the eyes, irritation, pain, eye tenderness and sensitivity to light. Certain individuals may also develop a pink to purplish color in the white region of the eye. Development of blood shot in the eyes and watery eyes are some of the other symptoms of episcleritis.

Diagnosis

A thorough examination of the eyes is the only diagnosis that is available for detecting episcleritis. Individuals, who have recurrent attacks of this condition, are taken for a blood test to analyze the underlying cause.

Treatment

Majority of the cases of episcleritis usually go away without any treatment. However, with corticosteroid eye drops symptoms resolve faster and patients recover quickly. Individuals, who frequently fall prey to recurrent bouts of episcleritis, are put on NSAIDs for faster relief from the symptoms.

References

Article

  1. Watson PG, Hazelman BL. The Sclera and Systemic Disorders. Philadelphia: WB Saunders; 1976.
  2. Watson PG. Episcleritis. In: Current Ocular Therapy. 5th ed. 809
  3. Roy FH. Ocular Differential Diagnosis. Vol 1. 7th ed. Baltimore: Williams & Wilkins; 2002.
  4. Rajoo SG, Gandhewar J. Recurrent episcleritis in relation to menstruation: a case report. Cornea. 2011; 30(9):1035-6 
  5. Honik G, Wong IG, Gritz DC. Incidence and prevalence of episcleritis and scleritis in Northern California. Cornea. 2013; 32(12):1562-6 
  6. Héron E, Gutzwiller-Fontaine M, Bourcier T. Scleritis and episcleritis: diagnosis and treatment. Rev Med Interne. 2014; 35(9):577-85 
  7. Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA. Clinical characteristics of a large cohort of patients with scleritis and episcleritis.Ophthalmology. 2012; 119(1):43-50 (ISSN: 1549-4713)
  8. Lim L, Suhler EB, Smith JR. Biologic therapies for inflammatory eye disease. Clin Experiment Ophthalmol. May-Jun 2006; 34(4):365-374.
  9. Williams CP, Browning AC, Sleep TJ. A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis. Eye. Sep 2004.
  10. Kolomeyer AM, Ragam A, Shah K, Do BK, Shah VP, Chu DS. Cyclo-oxygenase inhibitors in the treatment of chronic non-infectious, non-necrotizing scleritis and episcleritis. Ocul Immunol Inflamm. 2012; 20(4):293-9

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Last updated: 2019-07-11 22:18