Treatment of Episcleritis

9.1Treatment of Episcleritis

Episcleritis may or may not require treatment; scleritis always does. Although simple, diffuse episcleritis may produce low-grade aggravation and temporary cosmetic consequences for the patient, it does not absolutely require therapy, because untreated it will eventually resolve leaving no sequelae. Regrettably, topical steroid therapy appears to be the reflex treatment prescribed by many physicians in developed countries. This is regrettable not simply because of the potential side effects of such treatment, but because experience suggests that such treatment actually prolongs the overall duration of the patient’s problem: the number of recurrences following discontinuation of each episode of steroid therapy appears to be greater, and the so-called rebound effect, in which the episcleritis intensifies with each recurrent episode after discontinuation of steroid therapy, has been observed. Our philosophy, and that of Watson [1], is to leave simple episcleritis untreated except for comfort and supportive therapy, such as cold compresses and iced artificial tears. It appears that, on the basis of the results of randomized double-masked placebo-controlled clinical trial, topical nonsteroidal anti-inflammatory therapy is not effective [2].

If the patient demands treatment, or if the patient’s occupation is such that withholding treatment would produce a vocational disability (actor, television personality, etc.), we suggest treating the patient with episcleritis in the same

way in which the patient with scleritis is initially treated, that is, with systemic nonsteroidal antiinflammatory drug (NSAID) therapy. A substantial proportion of those individuals with nodular episcleritis will require treatment, and the systemic NSAIDs are typically effective. Table 9.1 lists the currently available NSAIDs, along with suggested initial dosage. As usual, package insert directions should be followed from the standpoint of frequency of hematological monitoring, and so on. We advise uninterrupted therapy for a minimum of 6 months, followed by subsequent attempts to taper and discontinue the medicine while observing for recurrence.

Episcleritis associated with some specific disease may, of course, require systemic NSAID therapy, but also typically requires addressing the specific etiology of the episcleritis. Atopic individuals require appropriate environmental controls and systemic antihistamine therapy, and may even require systemic calcineurin inhibitor therapy (e.g., cyclosporine). Patients with gout require allopurinol. Patients with rosacea require one of the systemic tetracyclines. Patients with a specific connective tissue disease who have episcleritis may or may not require systemic therapy with medications other than NSAIDs. Plaquenil (hydroxychloroquine; 200 mg twice daily by mouth), is often effective in treating the dermatological and superficial ocular (e.g., episcleritis) consequences of systemic lupus erythematosus (SLE). Patients with nodular episcleritis associated with rheumatoid arthritis usually respond to