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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 59  |  Issue : 1  |  Page : 32-37

A clinical study of episcleritis and scleritis


Community Health Center, Bandiku, Rajasthan, India

Date of Submission14-Jul-2020
Date of Decision07-Aug-2020
Date of Acceptance21-Sep-2020
Date of Web Publication27-Mar-2021

Correspondence Address:
Dr. Pawan N Jarwal
Community Health Center, Bandiku, Dausa, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_93_20

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  Abstract 


Purpose: Episcleritis and scleritis, considered as different forms of the same spectrum of disease, are clinically distinct, having different prognosis and requiring different management. They participate in a variety of systemic diseases, particularly in connective tissue disorders. As they are uncommon disorders, documentation of clinical experience with them is limited. In this study, the clinical profile and associated disorders of episcleritis and scleritis were studied. Methodology: Detailed clinical history was taken in every patient relating to ocular and systemic disorders. Ocular and systemic examinations were done in all patients. Essential investigations pertaining to the cases were done. The patients were followed up throughout the course of the study for a variable period. Results: One-fourth of episcleritis cases were of nodular type. All the six cases of scleritis were of anterior type. Episcleritis showed a peak age incidence in the third decade of life, whereas scleritis in the fourth decade. Episcleritis occurred slightly more commonly in females than males. Scleritis showed equal sex distribution. Fifty-five percent of episcleritis patients presented within 3rd week of onset of symptoms, whereas majority of scleritis patients presented during 3rd week of onset. Twenty five percent of episcleritis patients had recurrent disease. One out of 20 cases of episcleritis and one out of six cases of scleritis patients had an associated systemic disorder. In 45% of episcleritis patients, artificial tears were sufficient for treatment. In 15% of cases oral nonsteroidal anti-inflammatory drug (NSAID) was required for controlling their episcleral inflammation. In 5 out of 6 cases of scleritis, oral NSAID was sufficient for controlling inflammation. None of the episcleritis patients had a decreased best corrected visual acuity (BCVA). Whereas one-third of scleritis patients had a fall in BCVA. Conclusion: Episcleritis is a benign, self-limiting, and recurrent disorder which typically affects young adults. Scleritis of whatever variety is a serious condition and usually affects the older age group. Episcleritis patients do not develop any sight-threatening complications. Whereas a half of scleritis patients develop ocular complications, which are usually severe and sight threatening. In majority of episcleritis patients, topical medication will suffice. All patients with scleritis must be treated with systemic anti-inflammatory medications.

Keywords: Episcleritis, Scleritis, Necrotizing scleritis


How to cite this article:
Jarwal PN. A clinical study of episcleritis and scleritis. TNOA J Ophthalmic Sci Res 2021;59:32-7

How to cite this URL:
Jarwal PN. A clinical study of episcleritis and scleritis. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 May 6];59:32-7. Available from: https://www.tnoajosr.com/text.asp?2021/59/1/32/312286




  Introduction Top


Scleritis and episcleritis, considered as different forms of the same spectrum of disease involving sclera and episclera, are uncommon but important differential diagnoses for painful red eye.[1]

As structure of sclera is highly collagenous and is almost acellular and avascular, the inflammation tends to be chronic and recurrent.[2] It participates in a variety of systemic diseases, particularly in many connective tissue disorders.

Scleritis and episcleritis are clinically distinct, having different prognosis and requiring different management.[3] Episcleritis is a transient, self-limited disease involving only episcleral tissues, characterized by areas of radial engorged blood vessels, which can be moved over the underlying sclera.[4] While scleritis is a serious condition involving deeper sclera. Congested scleral vessels have a criss-cross pattern with distortion of normal vascular pattern and adhere to the sclera.[4]

About one-fourth of episcleritis patients and nearly half of scleritis patients have an associated systemic disorder. They may be the only initial clinical features of many potentially lethal systemic diseases. Rapid diagnosis and treatment may halt the progression of the diseases and their blinding complications.[3] Rarely scleritis may also be caused by an infectious etiology.[5]

Objectives

In this study, our aim is to study the clinical profile of scleritis and episcleritis patients attending the Eye Department at Community Health Center Bandikui, Dausa, Rajasthan,

  1. To describe the clinical characteristics and associated disorders of scleritis and episcleritis
  2. To study the management, complications, and visual prognosis.



  Methodology Top


The material for this study included the patients attending outpatient eye departments at Community health center Bandikui, Dausa, Rajasthan, during the period of March 2019 to February 2020, clinically diagnosed as episcleritis or scleritis.

A standard clinical pro forma was filled in all cases, which included salient points in history, clinical findings, laboratory investigations, and the treatment.

A detailed clinical history was taken in every patient relating to ocular and systemic disorders. Ocular examination including examination in daylight and slit-lamp examination were done in all cases. Consultation with other medical specialties was done, whenever needed.

A short differential diagnosis was made in each case. Essential investigations pertaining to the case were done in willing patients. Investigations included total and differential counts, erythrocyte sedimentation rate, serum uric acid estimation, venereal disease research laboratory test, Mantoux test, ultrasound B-scan, X-rays of chest and joints and microbiological examination of scleral/corneal scrapings.

An attempt was made in each case to establish the etiological diagnosis based on history, clinical features, laboratory investigations, and systemic evaluation. Many cases remained idiopathic.

All patients were treated medically and were followed up throughout the course of the study. The complications were noted, and the response to treatment was recorded, evaluated in each patient.

Patients who were noncompliant and not willing for follow up were excluded from the study.


  Results Top


In the present study, 26 patients with scleritis and episcleritis were studied irrespective of their age and sex. It included 20 patients with episcleritis and six patients with scleritis.

One-fourth of episcleritis cases were of nodular type. All the six cases of scleritis were of anterior type [Figure 1] and [Figure 2]. Two cases each of diffuse anterior scleritis (DAS) [Figure 3], nodular anterior scleritis [Figure 4], and surgically induced necrotizing scleritis (SINS) [Figure 5] were studied [Table 1].
Figure 1: Diffuse episcleritis

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Figure 2: Nodular episcleritis

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Figure 3: Diffuse scleritis

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Figure 4: Nodular scleritis

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Figure 5: Surgery induced necrotizing scleritis

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Table 1: Type of inflammation

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Episcleritis occurred maximally from the third to fifth decade of life with a peak incidence in the third decade. No case was seen below 10 years.

Scleritis showed peak incidence in the fourth decade. Both the cases of SINS were of more than 50 years of age [Table 2].
Table 2: Age distribution

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Episcleritis occurred slightly more commonly in females than males. Scleritis occurred evenly between males and females. But this finding must be interpreted cautiously as the total number of scleritis is small [Table 3].
Table 3: Sex distribution

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In this study, no case bilateral scleritis was seen. None of the bilateral episcleritis affected both eyes simultaneously [Table 4].
Table 4: Laterality in episcleritis

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Majority (55%) of patients with episcleritis presented within 1st week of onset of symptoms.

Whereas majority of scleritis patients presented during 3rd week of onset. Two patients who presented after 3 weeks were on treatment by a local doctor, before presenting to our hospital.

Twenty-five percent of episcleritis patients had recurrent disease. The period of recurrence ranged from 15 days to 5 years [Table 5].
Table 5: Duration of symptoms

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None of the scleritis cases had previous episodes [Table 6].
Table 6: Number of previous recurrence in episcleritis

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Episcleritis affected the interpalpebral region in about 80% of cases suggesting the possibility of external aggravating factors [Table 7].
Table 7: Distribution of inflammation

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In both cases of SINS, cataract extraction was the precipitating cause. One case of DAS was associated with miliary tuberculosis.

Out of 20 cases of episcleritis, only one case had an associated condition in the form of discoid lupus erythematosus [Table 8].
Table 8: Associated condition

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In 50% of cases of scleritis, one or more ocular complications were seen. Anterior uveitis occurred in one patient, whereas stromal keratitis occurred in two patients with scleritis.

In none of the cases of episcleritis, any ocular complications were noted [Table 9].
Table 9: Complications

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Forty-five percent of episcleritis cases were given symptomatic treatment with artificial tears. For those presenting early, topical steroid was given initially for aborting the attack. Two patients treated with artificial tears initially required topical steroid for subsidence of inflammation. Three patients required oral nonsteroidal anti-inflammatory drug (NSAID) drugs for controlling their episcleral inflammation [Table 10].
Table 10: Treatment given in episcleritis

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In 5 out of 6 cases of scleritis, oral NSAID was sufficient for controlling the inflammation. One patient with DAS with military tuberculosis received, in addition to antitubercular treatment, oral NSAID, and oral steroid therapy [Table 11].
Table 11: Treatment given in scleritis

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Two patients had visual acuity (VA) of 1/60. One of the patients had SINS with stromal keratitis. And the other had DAS with miliary tuberculosis. Visual loss in the latter patient was attributed to macular edema. Her best corrected VA (BCVA) improved to 6/60 with treatment after 1 week.

None of the episcleritis patients had a decreased BCVA [Table 12].
Table 12: Pre- and post-treatment best corrected visual acuity in scleritis

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  Discussion Top


Both forms of scleral inflammation are relatively uncommon, but episcleritis is less so. No population studies have yet been able to determine their true prevalence. Williamson surveyed the diagnosis of 9600 new patient referrals to eye departments of the Southern General Hospital and Victoria Infirmary in Glasgow and found only 8 of these patients had scleritis (0.08%).[6]

Simple episcleritis comprised three-fourth of total number of episcleritis. This is comparable to the result found in a study done by Watson and Hayreh in which out of 217 eyes with episcleritis, simple episcleritis accounted for 170 (78.3%) eyes.

In this study, all the scleritis cases were of anterior type. In one of the patients who presented with mild proptosis, chemosis, and posterior uveitis, posterior scleritis was strongly suspected. Unfortunately, the diagnosis could not be confirmed with B-scan ultrasonography, and patient lost to follow up. This case was not included in the present study. It was observed that episcleritis occurred maximally (75%) from the third to fifth decade of life, with a peak incidence in the third decade (40%). The condition was not seen below 10 years. It occurred slightly more commonly in females (55%) than males. 50% of patients with scleritis presented in the fourth and fifth decade. Both the cases of SINS were of more than 50 years of age. Scleritis showed even sex distribution. This finding is misleading as the total number of cases of scleritis is small.

In a study done by Jabs et al., mean age of onset of episcleritis was 45 years with a range of 9–71 years. Whereas the mean age of onset of scleritis was 51 years, and the range was 6–81 years. They noted a female preponderance in both forms of scleral inflammation.[7]

15% of cases of episcleritis showed bilateral disease, but none of them affected both eyes simultaneously. Twenty-five percent of patients with episcleritis had previous recurrent episodes. The period of recurrence ranged from 15 days to 5 years. According Watson, bilateral disease occurs in 36.5% of episcleritis cases.

Majority (55%) of patients with episcleritis presented within 1st week of onset of symptoms. Whereas 50% of patients with scleritis presented during 3rd week of onset and 83% presented within a month of onset of symptoms. This disparity in presentation can be attributed to acute onset of episcleritis, and more insidious onset of scleritis. And also, two patients with scleritis were on treatment by a local doctor, before presenting to our hospital.

According to a study by Watson PG, patients with scleritis attended much sooner after the onset of the disease than those with episcleritis.[3]

In about 80% of cases, episcleritis affected the interpalpebral region, whereas in 50% scleritis cases, the interpalpebral region was affected predominantly. This suggests the possibility of external aggravating factors in episcleritis. This finding is in agreement with the study done by McGavin et al. Frequently scleritis affects superior quadrant also.[8]

In one (5%) out of 20 cases of episcleritis, an associated condition was observed. One patient (16.6%) with DAS had military tuberculosis.

In the study by Watson and Hayreh done in a special scleritis clinic during 10 years period at a tertiary eye care referral hospital, out of 159 patients with episcleritis, 26% had an associated condition, and out of 20% patients with scleritis, 46% had an associated condition. Of these, 15% of patients had definite connective tissue disorder. Rheumatoid arthritis was the most common connective tissue disorder, seen in 10% of cases.[3]

In our study, in none of the cases, there was any association with connective tissue disorder. This can be attributed to small number of cases, and the study was conducted in a general ophthalmic clinic. In the above-cited study, 90% of patients who had rheumatoid arthritis were seen within a year of the start of the special clinic.

According to McGavin et al., incidence of scleritis in rheumatoid arthritis patients was 0.67% while incidence of episcleritis in rheumatoid arthritis was only 0.17%.[8] In none of the cases with episcleritis, any ocular complications occurred.

Jabs et al. found ocular complications in 58.8% of patients with scleritis and in 13.5% of cases with episcleritis in their series. Similar observation was also made by Watson and Hayreh in their study. They observed 15% of episcleritis patients and 57% of scleritis patients to have ocular complications.[7] Again both of these studies were done in a tertiary eye care referral hospitals.

Majority (85%) of patients with episcleritis were treated with topical medication only, and only three patients (15%) required oral NSAIDs for control of their inflammation. Topical steroids were given to those patients who presented early in their disease, whereas those who presented in regressive phase of the disease were given only artificial tears. Cold compress was advised in all patients. Two patients treated with artificial tears initially required topical steroid for subsidence of inflammation. These findings support the fact that episcleritis is a benign and self-limiting disease.

All the scleritis patients received systemic anti-inflammatory medications. In 5 out of 6 cases (83.3%), oral NSAID was sufficient for controlling the inflammation. One patient with DAS with military tuberculosis received, in addition to Anti-tubercular therapy (ATT), oral NSAID, and oral steroid therapy.

In the series by Jabs et al., only 16.7% patients with episcleritis required more than topical corticosteroid for treatment, who required oral NSAIDs. 30.4% of patients with scleritis required oral NSAIDs, 31.9% required oral steroids and 26.1% required systemic immunosuppressive drugs.[7]

None of the episcleritis patients had a fall in BCVA, whereas three (50%) patients with scleritis had a fall in BCVA. Both cases of SINS had reduced BCVA at presentation. In the patient with military tuberculosis, the reduction in VA was attributed to macular lesions in the absence of posteriors scleritis. Her VA improved after 2 weeks of systemic anti-inflammatory treatment.


  Conclusion Top


Episcleritis and scleritis, considered as the different forms of scleral inflammation, are relatively uncommon and present as red eye with or without pain. They cover a spectrum ranging from trivial self-limiting episodes to a necrotizing process that may threaten vision.

Episcleritis is a benign, self-limiting, recurrent, and frequently bilateral disorder which typically affects young adults. Scleritis of whatever variety is a serious condition and usually affects the older age group. Episcleritis usually presents with an acute onset of redness and discomfort and characterized clinically by areas of radial inflamed superficial episcleral vascular network. Whereas scleritis presents insidiously with severe pain in the eye and redness. All varieties of scleritis develop scleral edema, intense congestion of deep episcleral vascular network.[9] Only a minority of episcleritis patients exhibit associated systemic condition, whereas nearly a half of scleritis patients do the same. Therefore in order to rule out any underlying systemic disease and to determine the extent and severity of the ocular disease, a comprehensive and cost-effective laboratory evaluation must be undertaken. Episcleritis may require a modest work up whereas scleritis patients usually require a more extensive workup.

In majority of episcleritis patients, topical mediations will suffice. For those who present in regressive phase of the disease, only symptomatic treatment should be given. All patients with scleritis must be treated with systemic anti-inflammatory medications. Systemic NSAIDs in high doses are usually the first line of treatment in all types of scleritis except in necrotizing scleritis. Systemic steroids and immunosuppressive drugs are used when there is a failure of response.[10]

Only a minority of patients with episcleritis develop ocular complications. The complications in episcleritis are typically subtle and not sight threatening. Therefore none of the patients show any fall in VA. Whereas a half of scleritis patients develop ocular complications, which are usually severe and sight threatening.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sihota R, Tandon R. Parson's Diseases of the Eye. 19th ed. New Delhi: Butterworth-Heinemann; 2003.  Back to cited text no. 1
    
2.
Duke-Elder L. System of Ophthalmology. Vol. VIII B. London: Henry Kimpton Publishers; 1973.  Back to cited text no. 2
    
3.
Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol 1976;60:163.  Back to cited text no. 3
    
4.
Wilhelmus KR, Huang A, Hwang DG, Parrish CM, Sutphin JE, Whitsett JC. Basic and Clinical Science Course-Section 3. San Francisco: The foundation of the American Academy of Ophthalmology; 2001.  Back to cited text no. 4
    
5.
Reynolds MG, Alfonso E. Treatment of infectious scleritis and kerato scleritis. Am J Ophthalmol 1991;112:543.  Back to cited text no. 5
    
6.
Williamson J. Incidence of eye disease in cases of connective tissue disease. Trans Ophthalmol Soc U K 1974;94:742-52.  Back to cited text no. 6
    
7.
Lyne AJ, Lloyd-Jones D. Necrotizing scleritis after ocular surgery. Trans Ophthalmol Soc U K 1979;99:146-9.  Back to cited text no. 7
    
8.
McGavin DD, Williamson J, Forrester JV, Foulds WS, Buchanan WW, Dick WC, et al. Episcleritis and scleritis. A study of their clinical manifestations and association with rheumatoid arthritis. Br J Ophthalmol 1976;60:192-226.  Back to cited text no. 8
    
9.
Bron AJ, Tripathi RC, Tripathi BJ. Wolf's anatomy of the eye and orbit. 8th ed. London: Chapman and Hall; 1997.  Back to cited text no. 9
    
10.
Nachiappan K, Biswas J, Kannan N. Clinical profile, Systemic associations and role of immuno suppressive therapy in management of necrotizing scleritis. In: Raju NS, editor. Proceedings 2003. 61st Annual Conference of All India Ophthalmology Society. New Delhi: AIOS; 2003. p. 6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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