Episcleritis: Difference between revisions

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'''Episcleritis''' is an acute, recurrent, benign inflammatory condition
'''Episcleritis''' is an acute, recurrent, benign inflammatory condition
of the loose connective tissue lying superficial to the sclera and deeper to the conjunctiva.
of the loose connective tissue lying superficial to the sclera and deeper to the conjunctiva.
==Historical Perspective==
[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].
The association between [important risk factor/cause] and [disease name] was made in/during [year/event].
In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].
In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].
There have been several outbreaks of [disease name], including -----.
In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].


==Classification==
==Classification==
Line 34: Line 21:


==Pathophysiology==
==Pathophysiology==
The exact pathogenesis of [disease name] is not fully understood.
The exact pathogenesis of Episcleritis is not fully understood.
 
OR
 
It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
 
OR
 
[Pathogen name] is usually transmitted via the [transmission route] route to the human host.
 
OR
 
Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
 
OR
 
 
[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
 
OR
 
The progression to [disease name] usually involves the [molecular pathway].
 
OR
 
The pathophysiology of [disease/malignancy] depends on the histological subtype.


==Causes==
==Causes==
Episcleritis has been associated with a large number systemic morbidities.
Episcleritis has been associated with a large number systemic morbidities. The commoner systemic conditions associated with episcleritis are atopy [[Rheumatoid arthritis]], [[Spondyloarthritis]], [[Inflammatory bowel disease]], [[Systemic lupus erythematosus]], [[Relapsing polychondritis]], [[Gout]]. Rarely it may be associated with [[IgA nephropathy]], [[Lyme disease]] and drug reaction to pamidronate.
The commoner systemic conditions associated with episcleritis are atopy
Rheumatoid arthritis, Spondyloarthritis, Inflammatory bowel disease, Systemic lupus erythematosus,Relapsing polychondritis, Gout
Rarely it may be associated with IgA nephropathy, Lyme disease and drug reaction to pamidronate.


==Differentiating Episcleritis from Other Diseases==
[[Rosacea|Acne rosacea]] is the commonest ocular comorbid condition with
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
episcleritis and is typically seen in patients with eyelid and corneal
 
involvement. The ocular disease often precedes dermatological manifestations.
OR
Episcleritis is also frequently seen as part of the spectrum of
 
[[Allergic conjunctivitis|atopic keratoconjunctivitis]] and dry eye syndrome.
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
 
Episcleritis is overwhelmingly a disease of adults affecting a wide range of age groups; pediatric age group involvement is rare.<ref name="Akpek 1999 pp. 729–731">{{cite journal | last=Akpek | first=E | title=Severity of episcleritis and systemic disease association | journal=Ophthalmology | publisher=Elsevier BV | volume=106 | issue=4 | date=1999-04-01 | issn=0161-6420 | pmid=10201593 | doi=10.1016/s0161-6420(99)90157-4 | pages=729–731}}</ref> The sex distribution varies between published
Episcleritis is overwhelmingly a disease of adults affecting a wide range of age groups; pediatric age group involvement is rare. The sex distribution varies between published
series but those series that describe an association with rheumatic diseases tend to have a female preponderance. Episcleritis is uncommon and the exact etiology of episcleritis is difficult to ascertain.  
series but those series that describe an association with rheumatic diseases tend to have a female preponderance. Episcleritis is uncommon and the exact etiology of episcleritis is difficult to ascertain.  
Diffuse episcleritis is more common than nodular episcleritis.The majority of patients with episcleritis have mild evanescent disease that usually does not require ophthalmological intervention and treatment.
Diffuse episcleritis is more common than nodular episcleritis.<ref name="Sainz de la Maza Jabbur Foster 1994 pp. 389–96">{{cite journal | last=Sainz de la Maza | first=M | last2=Jabbur | first2=NS | last3=Foster | first3=CS | title=Severity of scleritis and episcleritis. | journal=Ophthalmology | volume=101 | issue=2 | year=1994 | issn=0161-6420 | pmid=8115160 | pages=389–96}}</ref>The majority of patients with episcleritis have mild evanescent disease that usually does not require ophthalmological intervention and treatment.


==Risk Factors==
==Risk Factors==
There are no established risk factors for [disease name].
There are no established risk factors for Episcleritis.


OR
==Clinical Presentation==
The onset of episcleritis is usually acute and the patient presents with discomfort rather than severe pain .The pain if present in Episcleritis is usually a  mild discomfort and localized to the eye, rather than the typical boring pain associated with severe headache in scleritis.


The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
Rarely, episcleritis may be associated foreign body sensation and epiphora. The hallmark signs of episcleritis are oedema and inflammation of the episclera and injection and dilatation of the episcleral blood vessels. The sclera and subtarsal conjunctiva are not involved but
the conjunctiva overlying the inflamed area is always affected. There is no scleral swelling or necrosis and the intraocular structures
are typically not involved. The visual acuity is normal as long as there is no co-morbidity.  


OR
In diffuse episcleritis there is diffuse swelling and
oedema of a sector of the episclera in around two-thirds of patients
or of the whole eye in around one-third of patients. The redness varies in intensity, but is always red or pink
(rather than the bluish, brawny red colour seen in diffuse scleritis),
and the episcleral vessels, although engorged, retain their characteristic radial orientation.<ref name="Akpek 1999 pp. 729–731">{{cite journal | last=Akpek | first=E | title=Severity of episcleritis and systemic disease association | journal=Ophthalmology | publisher=Elsevier BV | volume=106 | issue=4 | date=1999-04-01 | issn=0161-6420 | pmid=10201593 | doi=10.1016/s0161-6420(99)90157-4 | pages=729–731}}</ref>


Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
The eye is generally not tender to touch. In nodular episcleritis , the oedema and infiltration is
localized to one part of the globe. A raised nodule forms within
the episcleral tissue. It is bright red to pink in colour and often has overlying or surrounding vascular irregularity. The nodule may be
tender to touch and is usually mobile. There is generally only one nodule at any one time and the nodules do not undergo necrosis.


OR
Careful slit lamp examination of the episclera, sclera, and the blood vessels is essential to differentiate episcleritis from scleritis.
 
In patients with episcleritis there is oedema of the episclera and
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.
dilatation of the conjunctival vessels. There is no oedema of the underlying sclera. The lack of scleral involvement is often easiest
to appreciate using red-free light and after blanching the superficial conjunctival vessels with phenylephrine 10%. After an attack of episcleritis the eye returns completely to normal,
but after repeated attacks over a long period of time there
may be some mild scleral thinning.


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
There is insufficient evidence to recommend routine screening for Episcleritis.
 
OR
 
According to the [guideline name], screening for [disease name] is not recommended.
 
OR
 
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
Episcleral inflammation adjacent to the cornea can lead to mild peripheral corneal infiltrate or oedema, and
Episcleral inflammation adjacent to the cornea can lead to mild peripheral corneal infiltrate or oedema, and
the peripheral cornea can be left thinned or vascularized.  
the peripheral cornea can be left thinned or vascularized. Recurrent attacks of episcleritis over a long time can cause mild scleral thinning, which is of no consequence to the integrity of the eye. The most common complications seen in patients with episcleritis are related to the use of long-term topical corticosteroids.
Recurrent attacks of episcleritis over a long time can cause mild scleral thinning, which is of no consequence to the integrity of the
eye.
The most common complications seen in patients with episcleritis are related to the use of long-term topical corticosteroids.
The use of long-term topical corticosteroids can lead to Cataract, ocular hypertension, and steroid-induced glaucoma. Rarely, topical corticosteroids may also induce herpetic
The use of long-term topical corticosteroids can lead to Cataract, ocular hypertension, and steroid-induced glaucoma. Rarely, topical corticosteroids may also induce herpetic
keratitis. These treatment-related complications are the commonest causes of visual loss in patients with episcleritis.
keratitis. These treatment-related complications are the commonest causes of visual loss in patients with episcleritis.
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a normal vascular pattern but the flow rate is generally faster than
a normal vascular pattern but the flow rate is generally faster than
normal and the whole transit of dye may be completed within two
normal and the whole transit of dye may be completed within two
to three seconds.
to three seconds.<ref name="Meyer 1988 pp. 533–546">{{cite journal | last=Meyer | first=Paul A R | title=Patterns of blood flow in episcleral vessels studied by low-dose fluorescein videoangiography | journal=Eye | publisher=Springer Nature | volume=2 | issue=5 | year=1988 | issn=0950-222X | doi=10.1038/eye.1988.104 | pages=533–546}}</ref>


High definition anterior segment ultrasound helps in differentiating episcleritis from scleritis but is rarely
High definition anterior segment ultrasound helps in differentiating episcleritis from scleritis but is rarely
necessary clinically
necessary clinically.


==Treatment==
==Treatment==

Latest revision as of 20:50, 3 March 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Rohan Bir Singh, M.B.B.S.[2]

Synonyms and keywords:

Overview

Episcleritis is an acute, recurrent, benign inflammatory condition of the loose connective tissue lying superficial to the sclera and deeper to the conjunctiva.

Classification

Inflammation of the episclera is classified by its location and severity using the system devised by Watson.[1]

Classification of Episcleritis
Episcleritis
  • Diffuse
  • Nodular

Pathophysiology

The exact pathogenesis of Episcleritis is not fully understood.

Causes

Episcleritis has been associated with a large number systemic morbidities. The commoner systemic conditions associated with episcleritis are atopy Rheumatoid arthritis, Spondyloarthritis, Inflammatory bowel disease, Systemic lupus erythematosus, Relapsing polychondritis, Gout. Rarely it may be associated with IgA nephropathy, Lyme disease and drug reaction to pamidronate.

Acne rosacea is the commonest ocular comorbid condition with episcleritis and is typically seen in patients with eyelid and corneal involvement. The ocular disease often precedes dermatological manifestations. Episcleritis is also frequently seen as part of the spectrum of atopic keratoconjunctivitis and dry eye syndrome.

Epidemiology and Demographics

Episcleritis is overwhelmingly a disease of adults affecting a wide range of age groups; pediatric age group involvement is rare.[2] The sex distribution varies between published series but those series that describe an association with rheumatic diseases tend to have a female preponderance. Episcleritis is uncommon and the exact etiology of episcleritis is difficult to ascertain. Diffuse episcleritis is more common than nodular episcleritis.[3]The majority of patients with episcleritis have mild evanescent disease that usually does not require ophthalmological intervention and treatment.

Risk Factors

There are no established risk factors for Episcleritis.

Clinical Presentation

The onset of episcleritis is usually acute and the patient presents with discomfort rather than severe pain .The pain if present in Episcleritis is usually a mild discomfort and localized to the eye, rather than the typical boring pain associated with severe headache in scleritis.

Rarely, episcleritis may be associated foreign body sensation and epiphora. The hallmark signs of episcleritis are oedema and inflammation of the episclera and injection and dilatation of the episcleral blood vessels. The sclera and subtarsal conjunctiva are not involved but the conjunctiva overlying the inflamed area is always affected. There is no scleral swelling or necrosis and the intraocular structures are typically not involved. The visual acuity is normal as long as there is no co-morbidity.

In diffuse episcleritis there is diffuse swelling and oedema of a sector of the episclera in around two-thirds of patients or of the whole eye in around one-third of patients. The redness varies in intensity, but is always red or pink (rather than the bluish, brawny red colour seen in diffuse scleritis), and the episcleral vessels, although engorged, retain their characteristic radial orientation.[2]

The eye is generally not tender to touch. In nodular episcleritis , the oedema and infiltration is localized to one part of the globe. A raised nodule forms within the episcleral tissue. It is bright red to pink in colour and often has overlying or surrounding vascular irregularity. The nodule may be tender to touch and is usually mobile. There is generally only one nodule at any one time and the nodules do not undergo necrosis.

Careful slit lamp examination of the episclera, sclera, and the blood vessels is essential to differentiate episcleritis from scleritis. In patients with episcleritis there is oedema of the episclera and dilatation of the conjunctival vessels. There is no oedema of the underlying sclera. The lack of scleral involvement is often easiest to appreciate using red-free light and after blanching the superficial conjunctival vessels with phenylephrine 10%. After an attack of episcleritis the eye returns completely to normal, but after repeated attacks over a long period of time there may be some mild scleral thinning.

Screening

There is insufficient evidence to recommend routine screening for Episcleritis.

Natural History, Complications, and Prognosis

Episcleral inflammation adjacent to the cornea can lead to mild peripheral corneal infiltrate or oedema, and the peripheral cornea can be left thinned or vascularized. Recurrent attacks of episcleritis over a long time can cause mild scleral thinning, which is of no consequence to the integrity of the eye. The most common complications seen in patients with episcleritis are related to the use of long-term topical corticosteroids. The use of long-term topical corticosteroids can lead to Cataract, ocular hypertension, and steroid-induced glaucoma. Rarely, topical corticosteroids may also induce herpetic keratitis. These treatment-related complications are the commonest causes of visual loss in patients with episcleritis.

Diagnosis

When diagnosed clinically, a small number of serological tests to ascertain associative autoimmune diseases like rheumatoid arthritis or systemic lupus erythematosus may be useful.

Anterior segment fluorescein angiography in episcleritis reveals a normal vascular pattern but the flow rate is generally faster than normal and the whole transit of dye may be completed within two to three seconds.[4]

High definition anterior segment ultrasound helps in differentiating episcleritis from scleritis but is rarely necessary clinically.

Treatment

Medical Therapy

Episcleritis is a self-limiting disease, thus it doesn't frequently require any treatment. If the symptoms are severe to require treatment, topical steroids generally provide rapid symptomatic relief and have proven benefit over topical non-steroidal anti-inflammatory treatment and topical lubricants.

Systemic treatment with oral non-steroidal antiinflammatory drugs such as cyclo-oxygenase inhibitors, may be required for episcleritis. In general any systemic disease should be treated on its merits and the episcleritis treated as necessary. Any local ocular disease, such as acne rosacea, atopy, or keratoconjunctivitis sicca that may be causing or contributing to the episcleritis, should be treated aggressively.

References

  1. Watson PG, Hayreh SS (1976). "Scleritis and episcleritis". Br J Ophthalmol. 60 (3): 163–91. PMC 1042706. PMID 1268179.
  2. 2.0 2.1 Akpek, E (1999-04-01). "Severity of episcleritis and systemic disease association". Ophthalmology. Elsevier BV. 106 (4): 729–731. doi:10.1016/s0161-6420(99)90157-4. ISSN 0161-6420. PMID 10201593.
  3. Sainz de la Maza, M; Jabbur, NS; Foster, CS (1994). "Severity of scleritis and episcleritis". Ophthalmology. 101 (2): 389–96. ISSN 0161-6420. PMID 8115160.
  4. Meyer, Paul A R (1988). "Patterns of blood flow in episcleral vessels studied by low-dose fluorescein videoangiography". Eye. Springer Nature. 2 (5): 533–546. doi:10.1038/eye.1988.104. ISSN 0950-222X.


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