Episcleritis
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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 | |
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| Episcleritis |
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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.
Epidemiology and Demographics
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. 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.
Risk Factors
There are no established risk factors for Episcleritis.
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.
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.