Episcleritis 5/29/2014
Episcleritis LEN V KOH OD
2014 PUCO 1
Introduction Abrupt onset of inflammation 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 disease
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
2014 PUCO 6
Koh‐PUCO 2 Episcleritis 5/29/2014
Disease Association (Rare) SIMPLE EPISCLERITIS NODULAR EPISCLERITIS Seronegative spondyloarthritides Idiopathic Inflammatory bowel disease Rheumatoid arthritis (6%) ANCA‐associated vasculitis
2014 PUCO 7
Medication‐Induced
2014 PUCO 8
Pathogenesis NONIMMUNE IMMUNE Dry eye syndrome Acute type 1 hypersensitivity Type 3 hypersensivity Syphillis or tuberculosis Type 4 delayed hypersensitivity
2014 PUCO 9
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
2014 PUCO 11
What are the differential diagnoses for episcleritis? A. subconjunctival hemorrhage B. conjunctivitis C. blepharitis D. keratitis E. scleritis F. acute anterior uveitis G. acute angle‐closure glaucoma
2014 PUCO 12
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 choroid
Slit‐lamp (red‐free) Yellow patch Scleral edema, vessels, avascular patches
10% phenylephrine 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
2014 PUCO 17
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) ◦ Lupus
2014 PUCO 18
Koh‐PUCO 6 Episcleritis 5/29/2014
Imaging & Other testing Chest x‐ray Endoscopy
2014 PUCO 19
How is episcleritis managed? A. Topical lubricants B. Topical NSAIDs C. Topical steroids D. Oral NSAIDs E. Oral Steroids
2014 PUCO 20
TREATMENTS Topical lubricants Oral NSAIDs ◦ 4‐6X per day ◦ Indomethacin 25 mg tid Topical NSAIDs ◦ Diclofenac qid Topical glucocorticoids ◦ FML or PF qid
2014 PUCO 21
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
2014 PUCO 22
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
2014 PUCO 23
References
2014 PUCO 24
Koh‐PUCO 8