Nodular episcleritis

Episcleritis is clinically classified as either simple or nodular. Simple episcleritis is usually the milder form, being limited to a sector of the eye in approximately two-thirds of cases, but can affect the entire episclera in approximately one-third of cases. Nodnlar episcleritis is nsually more serious and involves the presence of a definitive nodule and mild to moderate discomfort. Approximately 20% to 25% of cases present as nodular. Only 2% to 5% of episcleritis progresses to scleritis. Simple episcleritis usually lasts 1 to 3 weeks, whereas nodular episcleritis has a more variable course, in some cases lasting up to 2 months. Both forms periodically recnr but become less frequent with time until the disease no longer remits. Either form may recur as the other. 

In nodular episcleritis there is usually only a single distinct, elevated, red, edematous nodule with surroimd-ing congestion (see Figure 28-1). This classification is localized to discrete areas, each of which consists of an elevated nodule that is mobile over the underlying sclera. Because edema is isolated to the episclera, a biomicroscope slit beam does not show any upward deviation of the underlying sclera. Nodules vary in size and elevation,... 

Figure 28-1 Nodular episcleritis in sectorial configuration. Arrow points to elevated edematous nodule.

Nodular episcleritis is similar to diffuse but may have a more insidious onset and longer duration. In severe cases of episcleritis, one may observe rare anterior chamber cells that resolve with the episcleritis and do not represent a true uveitis. In the case of concurrent uveitis and episcleritis, the uveitis treatment may also control the episcleritis, and a systemic evaluation may be indicated to explore the possibility of an underlying etiology. 

Episcleritis is a self-limiting disease with minimal symptoms and risk therefore it generally does not require treatment, and patients should be encouraged to let the condition run its course. Simple anterior episcleritis, in particular, tends to greatly improve within 1 week and resolve by 3 weeks. Lubricants, particularly cold artificial tears, and cold compress can be used as supportive measures. Often, however, patients desire symptomatic reUef from the redness and discomfort. In other cases, particularly nodular episcleritis, there may be some discomfort. 

Figure 28-5 Focal scleral and episcleral inflammation seen in nodular scleritis.

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