Episcleritis

Last updated
Episcleritis
Episcleritiseye.jpg
Eye with Episcleritis
Specialty Ophthalmology
Symptoms Photophobia, hot/prickly/gritty sensation in eye, [1] Eye redness without pain, Watery eyes
TypesNodular and simple/diffuse
Diagnostic method History and physical examination
Differential diagnosis Scleritis, Pinguecula
Treatment Artificial tears, supportive care
Medication Topical corticosteroids
Non-steroidal anti-inflammatory drugs.
Prognosis Good

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.

Contents

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 year old female Episcleritis.jpg
Episcleritis of a 40 year old female

Symptoms of episcleritis typically include painless redness of the eye (mild pain is possible but atypical), and watery eyes. [2] The pain of episcleritis is typically mild, less severe than in scleritis, [3] and may be tender to palpation. [4]

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). [5] 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. [5]

Discharge is absent with episcleritis, and vision is unaffected. [5] Patients with episcleritis experience far less photophobia than patients with uveitis. [2] Episcleritis does not cause the presence of cells or flare in the anterior chamber of the eye. [2] In 80 percent of cases, episcleritis affects only one eye, [6] whereas scleritis often affects both eyes.

Pathophysiology

Episcleritis is caused by inflammation due to the activation of immune cells, including lymphocytes and macrophages. [6] Most of the time, the cause of episcleritis is never determined (idiopathic). An identifiable cause is discovered in about one third of cases. [7] 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), [8] psoriatic arthritis, ankylosing spondylitis, Cogan syndrome, rosacea, gout, [5] atopy, [7] Crohn's disease, and ulcerative colitis. [9] [6] 59 percent of patients with relapsing polychondritis have either episcleritis or scleritis. [10] Rarely, episcleritis may be caused by scleritis. [11] Very rarely, episcleritis is associated with infections, including Lyme disease, tuberculosis, syphilis, and herpes zoster. [6]

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. [5] 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. [5] 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. [3] 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.[ citation needed ] In very rare cases, if episcleritis does not respond to treatment, then a biopsy may be considered, [6] 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.[ citation needed ]

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. [7]

Ketorolac, a topical NSAID, may be used, but it is not more effective than artificial tears and it causes more side effects. [12]

Prognosis

Episcleritis is a benign, self-limiting condition, meaning patients recover without any treatment. Most cases of episcleritis resolve within 7–10 days. [2] The nodular type is more aggressive and takes longer to resolve. [2] Although rare, some cases may progress to scleritis. [13] However, in general, episcleritis does not cause complications in the eye. [13] Smoking tobacco delays the response to treatment in patients with episcleritis. [14]

Epidemiology

While episcleritis is a common disease, [15] its exact prevalence and incidence are unknown. [6] It typically affects young [15] or middle aged women. [6] The diffuse form of episcleritis (70%) is more common than the nodular form (30%). [6] One retrospective study found 28 percent of individuals with episcleritis experienced recurrent episodes of the disease. [16]

Related Research Articles

<span class="mw-page-title-main">Conjunctivitis</span> Inflammation of the eye

Conjunctivitis, also known as pink eye, is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid. It makes the eye appear pink or reddish. Pain, burning, scratchiness, or itchiness may occur. The affected eye may have increased tears or be "stuck shut" in the morning. Swelling of the white part of the eye may also occur. Itching is more common in cases due to allergies. Conjunctivitis can affect one or both eyes.

Rheumatology is a branch of medicine devoted to the diagnosis and management of disorders whose common feature is inflammation in the bones, muscles, joints, and internal organs. Rheumatology covers more than 100 different complex diseases, collectively known as rheumatic diseases, which includes many forms of arthritis as well as lupus and Sjögren's syndrome. Doctors who have undergone formal training in rheumatology are called rheumatologists.

<span class="mw-page-title-main">Sclera</span> White part of an eyeball

The sclera, also known as the white of the eye or, in older literature, as the tunica albuginea oculi, is the opaque, fibrous, protective outer layer of the eye containing mainly collagen and some crucial elastic fiber.

<span class="mw-page-title-main">Prednisolone</span> Chemical compound (steroid medication)

Prednisolone is a corticosteroid, a steroid hormone used to treat certain types of allergies, inflammatory conditions, autoimmune disorders, and cancers. Some of these conditions include adrenocortical insufficiency, high blood calcium, rheumatoid arthritis, dermatitis, eye inflammation, asthma, and multiple sclerosis. It can be taken by mouth, injected into a vein, used topically as a skin cream, or as eye drops. It differs from the similarly named prednisone in having a hydroxyl at the 11th carbon instead of a ketone.

<span class="mw-page-title-main">Dry eye syndrome</span> Medical condition

Dry eye syndrome, also known as keratoconjunctivitis sicca, is the condition of having dry eyes. Symptoms include dryness in the eye, irritation, redness, discharge, blurred vision, and easily fatigued eyes. Symptoms range from mild and occasional to severe and continuous. Dry eye syndrome can lead to blurred vision, instability of the tear film, increased risk of damage to the ocular surface such as scarring of the cornea, and changes in the eye including the neurosensory system.

<span class="mw-page-title-main">Granulomatosis with polyangiitis</span> Medical condition

Granulomatosis with polyangiitis (GPA), also known as Wegener's granulomatosis (WG), after the German physician Friedrich Wegener, is a rare long-term systemic disorder that involves the formation of granulomas and inflammation of blood vessels (vasculitis). It is an autoimmune disease and a form of vasculitis that affects small- and medium-size vessels in many organs but most commonly affects the upper respiratory tract, lungs and kidneys. The signs and symptoms of GPA are highly varied and reflect which organs are supplied by the affected blood vessels. Typical signs and symptoms include nosebleeds, stuffy nose and crustiness of nasal secretions, and inflammation of the uveal layer of the eye. Damage to the heart, lungs and kidneys can be fatal.

<span class="mw-page-title-main">Uveitis</span> Inflammation of the uvea of the eye

Uveitis is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and includes the iris, ciliary body, and choroid. Uveitis is described anatomically, by the part of the eye affected, as anterior, intermediate or posterior, or panuveitic if all parts are involved. Anterior uveitis (iridocyclitis) is the most common, with the incidence of uveitis overall affecting approximately 1:4500, most commonly those between the ages of 20-60. Symptoms include eye pain, eye redness, floaters and blurred vision, and ophthalmic examination may show dilated ciliary blood vessels and the presence of cells in the anterior chamber. Uveitis may arise spontaneously, have a genetic component, or be associated with an autoimmune disease or infection. While the eye is a relatively protected environment, its immune mechanisms may be overcome resulting in inflammation and tissue destruction associated with T-cell activation.

<span class="mw-page-title-main">Red eye (medicine)</span> Eye that appears red due to illness or injury

A red eye is an eye that appears red due to illness or injury. It is usually injection and prominence of the superficial blood vessels of the conjunctiva, which may be caused by disorders of these or adjacent structures. Conjunctivitis and subconjunctival hemorrhage are two of the less serious but more common causes.

<span class="mw-page-title-main">Allergic conjunctivitis</span> Medical condition

Allergic conjunctivitis (AC) is inflammation of the conjunctiva due to allergy. Although allergens differ among patients, the most common cause is hay fever. Symptoms consist of redness, edema (swelling) of the conjunctiva, itching, and increased lacrimation. If this is combined with rhinitis, the condition is termed allergic rhinoconjunctivitis (ARC).

Microscopic polyangiitis is an autoimmune disease characterized by a systemic, pauci-immune, necrotizing, small-vessel vasculitis without clinical or pathological evidence of granulomatous inflammation.

<span class="mw-page-title-main">Relapsing polychondritis</span> Medical condition

Relapsing polychondritis is a systemic disease characterized by repeated episodes of inflammation and in some cases deterioration of cartilage. The disease can be life-threatening if the respiratory tract, heart valves, or blood vessels are affected. The exact mechanism is poorly understood.

Ocular melanosis (OM) is a blue-gray and/or brown lesion of the conjunctiva that can be separated into benign conjunctival epithelial melanosis (BCEM) and primary acquired melanosis (PAM), of which the latter is considered a risk factor for uveal melanoma. The disease is caused by an increase of melanocytes in the iris, choroid, and surrounding structures. Overproduction of pigment by these cells can block the trabecular meshwork through which fluid drains from the eye. The increased fluid in the eye leads to increased pressure, which can lead to glaucoma. In humans, this is sometimes known as pigment dispersion syndrome.

<span class="mw-page-title-main">Scleritis</span> Medical condition

Scleritis is a serious inflammatory disease that affects the white outer coating of the eye, known as the sclera. The disease is often contracted through association with other diseases of the body, such as granulomatosis with polyangiitis or rheumatoid arthritis. There are three types of scleritis: diffuse scleritis, nodular scleritis, and necrotizing scleritis. Scleritis may be the first symptom of onset of connective tissue disease.

Sympathetic ophthalmia (SO), also called spared eye injury, is a diffuse granulomatous inflammation of the uveal layer of both eyes following trauma to one eye. It can leave the affected person completely blind. Symptoms may develop from days to several years after a penetrating eye injury. It typically results from a delayed hypersensitivity reaction.

<span class="mw-page-title-main">Corneal ulcer</span> Medical condition of the eye

Corneal ulcer, also called keratitis, is an inflammatory or, more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and in farming. In developing countries, children afflicted by vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes persisting throughout life. In ophthalmology, a corneal ulcer usually refers to having an infection, while the term corneal abrasion refers more to a scratch injury.

Cerebral vasculitis is vasculitis involving the brain and occasionally the spinal cord. It affects all of the vessels: very small blood vessels (capillaries), medium-size blood vessels, or large blood vessels. If blood flow in a vessel with vasculitis is reduced or stopped, the parts of the body that receive blood from that vessel begins to die. It may produce a wide range of neurological symptoms, such as headache, skin rashes, feeling very tired, joint pains, difficulty moving or coordinating part of the body, changes in sensation, and alterations in perception, thought or behavior, as well as the phenomena of a mass lesion in the brain leading to coma and herniation. Some of its signs and symptoms may resemble multiple sclerosis. 10% have associated bleeding in the brain.

<span class="mw-page-title-main">Idiopathic orbital inflammatory disease</span> Medical condition

Idiopathic orbital inflammatory (IOI) disease refers to a marginated mass-like enhancing soft tissue involving any area of the orbit. It is the most common painful orbital mass in the adult population, and is associated with proptosis, cranial nerve palsy, uveitis, and retinal detachment. Idiopathic orbital inflammatory syndrome, also known as orbital pseudotumor, was first described by Gleason in 1903 and by Busse and Hochheim. It was then characterized as a distinct entity in 1905 by Birch-Hirschfeld. It is a benign, nongranulomatous orbital inflammatory process characterized by extraocular orbital and adnexal inflammation with no known local or systemic cause. Its diagnosis is of exclusion once neoplasm, primary infection and systemic disorders have been ruled out. Once diagnosed, it is characterized by its chronicity, anatomic location or histologic subtype.

<span class="mw-page-title-main">Herpes simplex keratitis</span> Medical condition

Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea.

Peripheral Ulcerative Keratitis (PUK) is a group of destructive inflammatory diseases involving the peripheral cornea in human eyes. The symptoms of PUK include pain, redness of the eyeball, photophobia, and decreased vision accompanied by distinctive signs of crescent-shaped damage of the cornea. The causes of this disease are broad, ranging from injuries, contamination of contact lenses, to association with other systemic conditions. PUK is associated with different ocular and systemic diseases. Mooren's ulcer is a common form of PUK. The majority of PUK is mediated by local or systemic immunological processes, which can lead to inflammation and eventually tissue damage. Standard PUK diagnostic test involves reviewing the medical history and a completing physical examinations. Two major treatments are the use of medications such as corticosteroids or other immunosuppressive agents and surgical resection of the conjunctiva. The prognosis of PUK is unclear with one study providing potential complications. PUK is a rare condition with an estimated incidence of 3 per million annually.

References

  1. ↑ "Episcleritis". Autoimmune Registry Inc. Retrieved 15 June 2022.
  2. 1 2 3 4 5 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.
  3. 1 2 Goldman, Lee (2011). Goldman's Cecil Medicine (24th ed.). Philadelphia: Elsevier Saunders. pp.  2440. ISBN   978-1437727883.
  4. ↑ 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.
  5. 1 2 3 4 5 6 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.
  6. 1 2 3 4 5 6 7 8 Schonberg, S; Stokkermans, TJ (January 2020). "Episcleritis". PMID   30521217.{{cite journal}}: Cite journal requires |journal= (help)
  7. 1 2 3 Yanoff, Myron; Jay S. Duker (2008). Ophthalmology (3rd ed.). Edinburgh: Mosby. pp. 255–261. ISBN   978-0323057516.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ Sabatine, Marc S. (2011). Pocket Medicine (4th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p.  8–4. ISBN   978-1608319053.
  11. ↑ "Episcleritis: MedlinePlus Medical Encyclopedia". Bethesda, MD: United States National Library of Medicine . Retrieved 20 June 2010.
  12. ↑ 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. 19 (7): 739–42. doi: 10.1038/sj.eye.6701632 . PMID   15359265.
  13. 1 2 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.
  14. ↑ 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.
  15. 1 2 Levsky M.E.; DeFlorio P. (2010). Atlas of emergency medicine: Chapter 2 Ophthalmologic Conditions (3rd ed.). New York: McGraw-Hill Professional. ISBN   978-0071496186.
  16. ↑ 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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