Episcleritis 5/29/2014

Episcleritis LEN V KOH OD

2014 PUCO 1

Introduction Abrupt onset of in the episclera ◦ A mild, isolated problem ◦ Responds readily to topical therapy ◦ Typically resolves over a short course A small number of patients ◦ Have an underlying systemic

2014 PUCO 2

Anatomy A. Bulbar conjunctival plexus ◦ Freely moveable, hair‐like vessels ◦ Bright red when inflamed B. Episcleral plexus ◦ Straight, radially arranged ◦ Salmon pink color when inflamed C. Scleral plexus ◦ Immobile criss‐cross vessels ◦ Bluish‐red color, when inflamed

Koh‐PUCO 1 Episcleritis 5/29/2014

Classification

Nodular Diffuse

What is the epidemiology of episcleritis? A. More males B. More females C. Younger than 40 D. Older than 40 E. Older than 60

2014 PUCO 5

Epidemiology

Episcleritis 70% Females Mean age 47.4 years

Nodular, 30%

Diffuse, 70%

Diffuse Nodular

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Koh‐PUCO 2 Episcleritis 5/29/2014

Disease Association (Rare) SIMPLE EPISCLERITIS NODULAR EPISCLERITIS Seronegative spondyloarthritides Idiopathic Inflammatory bowel disease (6%) ANCA‐associated vasculitis

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Medication‐Induced

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Pathogenesis NONIMMUNE IMMUNE Acute type 1 hypersensitivity Type 3 hypersensivity Syphillis or Type 4 delayed hypersensitivity

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Koh‐PUCO 3 Episcleritis 5/29/2014

Symptoms SIMPLE EPISCLERITIS NODULAR EPISCLERITIS Acute onset Slow onset Mild or no pain Increasing discomfort Heat, prickling Worsens over several days Resolves over several days Recurrence is common

2014 PUCO 10

Exam Findings SIMPLE EPISCLERITIS NODULAR EPISCLERITIS Diffuse edema Localised edema with vascular congestion Mild flush to brick red Tender, mobile nodule(s) Interpalpebral fissure

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What are the differential diagnoses for episcleritis? A. subconjunctival hemorrhage B. C. D. E. F. acute anterior G. acute angle‐closure

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Koh‐PUCO 4 Episcleritis 5/29/2014

Episcleritis versus conjunctivitis Bacterial, viral, allergic Redness and discharge Diffuse injection 360◦

Conjunctivitis

2014 PUCO 13

Episcleritis versus scleritis Clinical Features Episcleritis Scleritis

In daylight Salmon pink Purple/grey

Slit‐lamp (red‐free) Yellow patch Scleral edema, vessels, avascular patches

10% More constriction Minimal constriction

Symptoms Mild or no pain Severe pain, phtophobia

Scleral edema No Yes or thinning

DIAGNOSIS 1st episode: complete eye exam with a thorough history Recurrence or other cormobidity: additional investigations

2014 PUCO 15

Koh‐PUCO 5 Episcleritis 5/29/2014

What are the basic lab work up? A. CBC B. Serum Chemistry C. Urinalysis D. ESR E. CRP

2014 PUCO 16

Basic Lab Workup Complete blood count ◦ WBC, platelet, or hematocrit Serum chemistry profile ◦ Creatinine, blood urea nitrogen Urinalysis with microscopy Acute phase reactants ◦ ESR, CRP

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Extensive Lab Workup Rheumatoid factor Serum complement C3, C4 ◦ Rheumatoid vasculitis Antibodies to dsDNA Antibodies to cyclic citrullinated Antibodies to Ro, La, Sm, or RNP peptides (anti‐CCP antibodies) antigens ◦ Rheumatoid arthritis Antineutrophil cytoplasmic antibodies (ANCA) ◦ Wegener’s polyangiitis Antinuclear antibody (ANA) ◦

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Koh‐PUCO 6 Episcleritis 5/29/2014

Imaging & Other testing Chest x‐ray Endoscopy

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How is episcleritis managed? A. Topical lubricants B. Topical NSAIDs C. Topical steroids D. Oral NSAIDs E. Oral Steroids

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TREATMENTS Topical lubricants Oral NSAIDs ◦ 4‐6X per day ◦ Indomethacin 25 mg tid Topical NSAIDs ◦ Diclofenac qid Topical glucocorticoids ◦ FML or PF qid

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Koh‐PUCO 7 Episcleritis 5/29/2014

PROGNOSIS Sx usually resolve in 7‐10 days Nodular may take longer Corneal infiltrates and low‐grade uveitis occur rarely

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CONCLUSIONS Episcleritis have a mild, isolated problem Responds to topical therapy alone A minority have an underlying systemic disease Episcleritis could be an early presentation of scleritis Accurate distinction between episcleritis and scleritis is critical

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References

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Koh‐PUCO 8