Treated for Bacterial Infection in Eye Now Hurts Again
Am Fam Medico. 2010 Jan 15;81(ii):137-144.
Patient information: See related handout on pinkish eye, written past the authors of this article.
Related alphabetic character: "Features and Serotypes of Chlamydial Conjunctivitis."
Article Sections
- Abstract
- Causes of Cerise Center
- Diagnosis and Treatment
- References
Red eye is the primal sign of ocular inflammation. The condition is ordinarily beneficial and tin can be managed by primary intendance physicians. Conjunctivitis is the most common cause of scarlet eye. Other common causes include blepharitis, corneal chafe, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis. Signs and symptoms of cerise eye include eye discharge, redness, pain, photophobia, itching, and visual changes. Mostly, viral and bacterial conjunctivitis are self-limiting conditions, and serious complications are rare. Because there is no specific diagnostic test to differentiate viral from bacterial conjunctivitis, near cases are treated using broad-spectrum antibiotics. Allergies or irritants also may cause conjunctivitis. The cause of red center can be diagnosed through a detailed patient history and careful eye test, and treatment is based on the underlying etiology. Recognizing the need for emergent referral to an ophthalmologist is key in the primary care direction of ruddy eye. Referral is necessary when severe hurting is non relieved with topical anesthetics; topical steroids are needed; or the patient has vision loss, copious purulent discharge, corneal involvement, traumatic eye injury, contempo ocular surgery, distorted pupil, herpes infection, or recurrent infections.
Cherry eye is one of the most common ophthalmologic conditions in the principal care setting. Inflammation of near whatsoever part of the centre, including the lacrimal glands and eyelids, or faulty tear film can atomic number 82 to cerise eye. Primary care physicians often effectively manage red eye, although knowing when to refer patients to an ophthalmologist is crucial.
SORT: Fundamental CLINICAL RECOMMENDATIONS
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Good hygiene, such as meticulous hand washing, is important in decreasing the spread of acute viral conjunctivitis. | C | 2, 4 |
| Whatever ophthalmic antibody may be considered for the treatment of acute bacterial conjunctivitis because they have similar cure rates. | A | 23–26 |
| Mild allergic conjunctivitis may be treated with an over-the-counter antihistamine/vasoconstrictor agent, or with a more effective second-generation topical histamine Hi receptor antagonist. | C | 15 |
| Anti-inflammatory agents (e.1000., topical cyclosporine [Restasis]), topical corticosteroids, and systemic omega-3 fatty acids are advisable therapies for moderate dry eye. | C | 32 |
| Patients with chronic blepharitis who do not respond adequately to eyelid hygiene and topical antibiotics may do good from an oral tetracycline or doxycycline. | C | 4, 33 |
Causes of Red Centre
- Abstract
- Causes of Cherry Eye
- Diagnosis and Treatment
- References
Conjunctivitis is the most common crusade of red center and is one of the leading indications for antibiotics.ane Causes of conjunctivitis may exist infectious (due east.one thousand., viral, bacterial, chlamydial) or noninfectious (e.g., allergies, irritants).2 Most cases of viral and bacterial conjunctivitis are self-limiting. Other common causes of red eye include blepharitis, corneal abrasion, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis.
A thorough patient history and eye examination may provide clues to the etiology of red center (Figure 1). The history should include questions nigh unilateral or bilateral heart involvement, duration of symptoms, type and corporeality of belch, visual changes, severity of hurting, photophobia, previous treatments, presence of allergies or systemic affliction, and the use of contact lenses. The heart examination should include the eyelids, lacrimal sac, pupil size and reaction to light, corneal involvement, and the pattern and location of hyperemia. Preauricular lymph node involvement and visual acuity must besides be assessed. Common causes of red heart and their clinical presentations are summarized in Tabular array ane.2–11
Diagnosis of the Underlying Cause of Red Heart
Figure 1.
Algorithm for diagnosing the cause of red middle.
Table 1.
Selected Differential Diagnosis of Red Eye
| Status | Signs | Symptoms | Causes |
|---|---|---|---|
| Conjunctivitis | |||
| Viral | Normal vision, normal student size and reaction to light, diffuse conjunctival injections (redness), preauricular lymphadenopathy, lymphoid follicle on the undersurface of the eyelid | Mild to no pain, diffuse hyperemia, occasional gritty discomfort with mild itching, watery to serous discharge, photophobia (uncommon), ofttimes unilateral at onset with second eye involved within 1 or two days, severe cases may cause subepithelial corneal opacities and pseudomembranes | Adenovirus (most common), enterovirus, coxsackievirus, VZV, Epstein-Barr virus, HSV, influenza |
| Herpes zoster ophthalmicus | Vesicular rash, keratitis, uveitis | Pain and tingling sensation precedes rash and conjunctivitis, typically unilateral with dermatomal involvement (periocular vesicles) | Herpes zoster |
| Bacterial (acute and chronic) | Eyelid edema, preserved visual vigil, conjunctival injection, normal pupil reaction, no corneal involvement | Mild to moderate pain with stinging sensation, ruddy eye with strange torso sensation, mild to moderate purulent belch, mucopurulent secretions with bilateral glued eyes upon awakening (best predictor) | Common pathogens in children: Streptococcus pneumoniae, nontypeable Haemophilus influenzae |
| Mutual pathogen in adults: Staphylococcus aureus | |||
| Other pathogens: Staphylococcus species, Moraxella species, Neisseria gonorrhoeae, gram-negative organisms (e.g., Escherichia coli), Pseudomonas species | |||
| Bacterial (hyperacute) | Chemosis with possible corneal involvement | Severe pain; copious, purulent discharge; macerated vision | N. gonorrhoeae |
| Chlamydial (inclusion conjunctivitis) | Vision usually preserved, pupils reactive to light, conjunctival injections, no corneal interest, preauricular lymph node swelling is sometimes present | Red, irritated eye; mucopurulent or purulent discharge; glued optics upon awakening; blurred vision | Chlamydia trachomatis (serotypes D to Thousand) |
| Allergic | Visual acuity preserved, pupils reactive to light, conjunctival injection, no corneal interest, large asphalt papillae under upper eyelid, chemosis | Bilateral eye involvement; painless tearing; intense itching; diffuse redness; stringy or ropy, watery belch | Airborne pollens, dust mites, animal dander, feathers, other ecology antigens |
| Other causes | |||
| Dry out center (kerato-conjunctivitis sicca) | Vision normally preserved, pupils reactive to light; hyperemia, no corneal involvement | Bilateral red, itchy eyes with foreign body awareness; mild pain; intermittent excessive watering | Imbalance in whatever tear component (product, distribution, evaporation, absorption); medications (anticholinergics, antihistamines, oral contraceptive pills); Sjögren syndrome |
| Blepharitis | Dandruff-like scaling on eyelashes, missing or misdirected eyelashes, swollen eyelids, secondary changes in conjunctiva and cornea leading to conjunctivitis | Ruddy, irritated center that is worse upon waking; itchy, crusted eyelids | Chronic inflammation of eyelids (base of eyelashes or meibomian glands) by staphylococcal infection |
| Corneal chafe and foreign body | Reactive miosis, corneal edema or brume, possible strange body, normal anterior chamber, visual acuity depends on the position of the abrasion in relation to visual axis | Unilateral or bilateral severe eye pain; red, watery eyes; photophobia; foreign body sensation; blepharospasm | Direct injury from an object (e.g., finger, paper, stick, makeup applicator); metal foreign trunk; contact lenses |
| Subconjunctival hemorrhage | Normal vision; pupils equal and reactive to light; well demarcated, bright red patch on white sclera; no corneal involvement | Mild to no hurting, no vision disturbances, no discharge | Spontaneous causes: hypertension, severe cough, straining, atherosclerotic vessels, haemorrhage disorders |
| Traumatic causes: edgeless center trauma, strange body, penetrating injury | |||
| Episcleritis | Visual vigil preserved, pupils equal and reactive to lite, dilated episcleral blood vessels, edema of episclera, tenderness over the expanse of injection, confined red patch | Mild to no pain; limited, isolated patches of injection; mild watering | Idiopathic (isolated presentation) |
| Keratitis (corneal inflammation) | Diminished vision, corneal opacities/white spot, fluorescein staining nether Woods lamp shows corneal ulcers, eyelid edema, hypopyon | Painful red eye, diminished vision, photophobia, mucopurulent discharge, strange torso sensation | Bacterial (Staphylococcus species, Streptococcus); viral (HSV, VZV, Epstein-Barr virus, cytomegalovirus); abrasion from foreign torso; contact lenses |
| Iritis | Diminished vision; poorly reacting, constricted pupils; ciliary/perilimbal injection | Abiding eye pain (radiating into forehead/temple) developing over hours, watering red center, blurred vision, photophobia | Exogenous infection from perforating wound or corneal ulcer, autoimmune conditions |
| Glaucoma (acute angle-closure) | Marked reduction in visual acuity, dilated pupils react poorly to calorie-free, diffuse redness, eyeball is tender and business firm to palpation | Astute onset of severe, throbbing pain; watering red heart; halos announced when patient is around lights | Obstruction to outflow of aqueous sense of humor leading to increased intraocular pressure |
| Chemic burn down | Diminished vision, corneal involvement (mutual) | Severe, painful crimson heart; photophobia | Common agents include cement, plaster powder, oven cleaner, and drain cleaner |
| Scleritis | Lengthened redness, macerated vision, tenderness, scleral edema, corneal ulceration | Severe, deadening pain radiating to periorbital area; pain increases with eye movements; ocular redness; watery belch; photophobia; intense night pain; hurting upon awakening | Systemic diseases, such as rheumatoid arthritis, Wegener granulomatosis, reactive arthritis, sarcoidosis, inflammatory bowel disease, syphilis, tuberculosis |
Diagnosis and Handling
- Abstract
- Causes of Ruby Centre
- Diagnosis and Treatment
- References
VIRAL CONJUNCTIVITIS
Viral conjunctivitis (Effigy ii) caused past the adenovirus is highly contagious, whereas conjunctivitis caused by other viruses (e.g., herpes simplex virus [HSV]) are less probable to spread. Viral conjunctivitis ordinarily spreads through direct contact with contaminated fingers, medical instruments, swimming pool water, or personal items. It is often associated with an upper respiratory infection spread through coughing. The clinical presentation of viral conjunctivitis is usually mild with spontaneous remission after one to two weeks.iii Treatment is supportive and may include cold compresses, ocular decongestants, and artificial tears. Topical antibiotics are rarely necessary because secondary bacterial infections are uncommon.12
To prevent the spread of viral conjunctivitis, patients should be counseled to do strict hand washing and avoid sharing personal items; nutrient handlers and health care workers should not work until eye discharge ceases; and physicians should clean instruments after every use.thirteen Referral to an ophthalmologist is necessary if symptoms do non resolve afterwards 7 to 10 days or if there is corneal involvement.4 Topical corticosteroid therapy for any crusade of blood-red middle is used only nether direct supervision of an ophthalmologist.v,12 Suspected ocular herpetic infection also warrants immediate ophthalmology referral.
Figure 2.
Viral conjunctivitis with intensely hyperemic conjunctiva, perilimbal sparing, and watery discharge.
BACTERIAL CONJUNCTIVITIS
Bacterial conjunctivitis is highly contagious and is virtually normally spread through direct contact with contaminated fingers.ii Based on duration and severity of signs and symptoms, bacterial conjunctivitis is categorized as hyperacute, acute, or chronic.4,12
Hyperacute bacterial conjunctivitis (Effigy 3 14) is frequently associated with Neisseria gonorrhoeae in sexually agile adults. The infection has a sudden onset and progresses rapidly, leading to corneal perforation. Hyperacute bacterial conjunctivitis is characterized by copious, purulent belch; pain; and macerated vision loss. Patients need prompt ophthalmology referral for aggressive management.4,12 Astute bacterial conjunctivitis is the most common form of bacterial conjunctivitis in the primary care setting. Signs and symptoms persist for less than three to 4 weeks. Staphylococcus aureus infection often causes acute bacterial conjunctivitis in adults, whereas Streptococcus pneumoniae and Haemophilus influenzae infections are more common causes in children. Chronic bacterial conjunctivitis is characterized by signs and symptoms that persist for at to the lowest degree four weeks with frequent relapses.2 Patients with chronic bacterial conjunctivitis should exist referred to an ophthalmologist.
Figure three.
Hyperacute bacterial conjunctivitis with reac-cumulating, copious, purulent belch; severe pain; chemosis with corneal involvement; and eyelid swelling. Prompt referral to an ophthalmologist is needed.
Reprinted with permission from Fay A. Diseases of the visual system. In: Goldman L, Ausillo D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa.: Saunders; 2007.
Laboratory tests to identify bacteria and sensitivity to antibiotics are performed merely in patients with severe cases, in patients with allowed compromise, in contact lens wearers, in neonates, and when initial handling fails.iv,15 Generally, topical antibiotics have been prescribed for the handling of acute infectious conjunctivitis because of the difficulty in making a clinical distinction between bacterial and viral conjunctivitis. Benefits of antibiotic handling include quicker recovery, early return to piece of work or school, prevention of farther complications, and decreased future physician visits.two,six,sixteen
A meta-analysis based on five randomized controlled trials showed that bacterial conjunctivitis is self-limiting (65 per centum of patients improved afterward ii to five days without antibiotic treatment), and that severe complications are rare.ii,7,sixteen–19 Studies prove that bacterial pathogens are isolated from simply 50 percent of clinically diagnosed bacterial conjunctivitis cases.8,sixteen Moreover, the utilise of antibiotics is associated with increased antibiotic resistance, additional expense for patients, and the medicalization of minor illness.iv,twenty–22 Therefore, delaying antibody therapy is an pick for acute bacterial conjunctivitis in many patients (Table ii).2,9 A shared decision-making approach is advisable, and many patients are willing to delay antibiotic therapy when counseled about the self-limiting nature of the disease. Some schools require proof of antibiotic treatment for at least two days before readmitting students,seven and this should exist addressed when making treatment decisions.
Table 2.
Management Options for Suspected Acute Bacterial Conjunctivitis
| Management option | Patient group |
|---|---|
| Consider immediate antibiotic therapy | Wellness care workers |
| Patients who are in a hospital or other health care facility | |
| Patients with risk factors, such every bit allowed compromise, uncontrolled diabetes mellitus, contact lens employ, dry center, or recent ocular surgery | |
| Children going to schools or day care centers that require antibiotic therapy before returning | |
| Consider delaying antibody therapy | Patients without risk factors who are well informed and have access to follow-up care |
| Patients without chance factors who practise not desire immediate antibody therapy |
Studies comparing the effectiveness of different ophthalmic antibiotics did non show one to be superior.23–26 The choice of antibody (Table 3) should be based on cost-effectiveness and local bacterial resistance patterns. If the infection does not improve inside ane calendar week of treatment, the patient should be referred to an ophthalmologist.iv,5
Tabular array 3.
Ophthalmic Therapies for Acute Bacterial Conjunctivitis
| Therapy | Usual dosage | Cost of generic (brand)* | In retail disbelieve programs† |
|---|---|---|---|
| Azithromycin i% (Azasite) | Solution: I drop two times daily (administered eight to 12 hours apart) for two days, then ane drop daily for v days | NA ($82) for 5 mL | |
| Besifloxacin 0.6% (Besivance) | Solution: One drop three times daily for one calendar week | NA ($85) for 5 mL | |
| Ciprofloxacin 0.3% (Ciloxan)‡ | Ointment: 0.5-inch ribbon applied in conjunctival sac 3 times daily for one week | Ointment: NA ($99) for 3.v g Solution: $30 ($65) for 5 mL | |
| Solution: One or 2 drops iv times daily for one week | |||
| Erythromycin 0.v% | Ointment: 0.5-inch ribbon applied 4 times daily for i week | $13 (NA) for 3.five g | ✓ |
| Gatifloxacin 0.iii% (Zymar) or moxifloxacin 0.five% (Vigamox)§ | Solution: One drop three times daily for one week | NA ($84) for 5 mL | |
| Gentamicin 0.3% (Gentak) | Ointment: 0.5-inch ribbon applied iv times daily for one calendar week | Ointment: NA ($22) for 3.five g | ✓ |
| Solution: One to two drops four times daily for one calendar week | Solution: $15 ($18) for 15 mL | ||
| Levofloxacin ane.5% (Iquix) or 0.v% (Quixin)‡ | Solution: I or 2 drops four times daily for one week | 1.5%: NA ($89) for 5 mL | |
| 0.v%: NA ($57) for 5 mL | |||
| Ofloxacin 0.3% (Ocuflox)‡ | Solution: One or two drops four times daily for ane week | $44 ($fourscore) for 5 mL | |
| Sulfacetamide 10% (Bleph-10) | Ointment: Apply to lower conjunctival sac four times daily and at bedtime for one week | $13 ($22) for v mL | ✓ |
| Solution: I or ii drops every two to three hours for one week | |||
| Tobramycin 0.3% (Tobrex) | Ointment: 0.v-inch ribbon applied in conjunctival sac three times daily for one week | Ointment: NA ($76) for three.five grand | ✓ |
| Solution: One to two drops 4 times daily for one calendar week | Solution: $16 ($threescore) for 5 mL | ||
| Trimethoprim/polymyxin B (Polytrim) | Solution: One or two drops four times daily for 1 week | NA ($42) for ten mL | ✓ |
CHLAMYDIAL CONJUNCTIVITIS
Chlamydial conjunctivitis should be suspected in sexually agile patients who have typical signs and symptoms and do not respond to standard antibacterial treatment.two Patients with chlamydial infection also may present with chronic follicular conjunctivitis. Polymerase concatenation reaction testing of conjunctival scrapings is diagnostic, but is not normally needed. Treatment includes topical therapy with erythromycin ophthalmic ointment, and oral therapy with azithromycin (Zithromax; single one-g dose) or doxycycline (100 mg twice a twenty-four hours for fourteen days) to clear the genital infection.four The patient'southward sexual partners besides must exist treated.
ALLERGIC CONJUNCTIVITIS
Allergic conjunctivitis is oft associated with atopic diseases, such as allergic rhinitis (most mutual), eczema, and asthma.27 Ocular allergies affect an estimated 25 percent of the population in the United states.28 Itching of the eyes is the most apparent characteristic of allergic conjunctivitis. Seasonal allergic conjunctivitis is the most common class of the status, and symptoms are related to flavor-specific aeroallergens. Perennial allergic conjunctivitis persists throughout the year. Allergic conjunctivitis is primarily a clinical diagnosis.
Avoiding exposure to allergens and using bogus tears are effective methods to convalesce symptoms. Over-the-counter antihistamine/vasoconstrictor agents are effective in treating mild allergic conjunctivitis. Another, more than constructive, option is a second-generation topical histamine Hane receptor antagonist.15 Table 4 presents ophthalmic therapies for allergic conjunctivitis.
Table 4.
Ophthalmic Therapies for Allergic Conjunctivitis
| Therapy | Usual dosage | Cost of generic (brand)* |
|---|---|---|
| Histamine Hone receptor antagonists† | ||
| Azelastine 0.05% (Optivar) | One drop twice daily | $140 ($108) for half dozen mL |
| Emedastine 0.05% (Emadine) | One drop iv times daily | NA ($72) for v mL |
| Mast prison cell stabilizers‡ | ||
| Cromolyn sodium 4% (Crolom) | One or two drops every 4 to vi hours | $32 ($45) for 10 mL |
| Lodoxamide 0.1% (Alomide) | 1 or ii drops four times daily | NA ($98) for 10 mL |
| Nedocromil two% (Alocril) | One or two drops twice daily | NA ($90) for 5 mL |
| Mast cell stabilizers and H1 receptor antagonists | ||
| Ketotifen 0.025% (Zaditor; available over the counter equally Alaway) | One driblet every eight to 12 hours | NA ($70) for 5 mL |
| Olopatadine 0.1% (Patanol) | 1 drop twice daily | NA ($96) for five mL |
| Nonsteroidal anti-inflammatory drugs | ||
| Ketorolac 0.5% (Acular) | 1 drib four times daily | $110 ($161) for five mL |
| Vasoconstrictor/antihistamine§ | ||
| Naphazoline/pheniramine (available over the counter as Opcon-A, Visine-A) | One or ii drops up to iv times daily | NA ($half-dozen to $xi) for 15 mL |
Dry Middle
Dry out eye (keratoconjunctivitis sicca) is a common status caused by decreased tear product or poor tear quality. It is associated with increased age, female sex, medications (due east.thousand., anticholinergics), and some medical atmospheric condition.29 Diagnosis is based on clinical presentation and diagnostic tests. Tear osmolarity is the best single diagnostic test for dry eye.30,31 The overall accuracy of the diagnosis increases when tear osmolarity is combined with cess of tear turnover rate and evaporation. Some patients with dry middle may have ocular discomfort without tear picture abnormality on examination. In these patients, treatment for dry eye can be initiated based on signs and symptoms. If Sjögren syndrome is suspected, testing for autoantibodies should exist performed.
Handling includes frequent applications of bogus tears throughout the solar day and nightly application of lubricant ointments, which reduce the rate of tear evaporation. The utilise of humidifiers and well-fitting eyeglasses with side shields can too decrease tear loss. If artificial tears cause itching or irritation, it may be necessary to switch to a preservative-complimentary course or an alternative preparation. When inflammation is the main factor in dry out eye, cyclosporine ophthalmic drops (Restasis) may increase tear production.five Topical cyclosporine may take several months to provide subjective improvement. Systemic omega-iii fatty acids have also been shown to be helpful.32 Topical corticosteroids are shown to be constructive in treating inflammation associated with dry out eye.32 The goal of handling is to prevent corneal scarring and perforation. Ophthalmology referral is indicated if the patient needs topical steroid therapy or surgical procedures.
BLEPHARITIS
Blepharitis is a chronic inflammatory status of the eyelid margins and is diagnosed clinically. Patients should be examined for scalp or facial skin flaking (seborrheic dermatitis), facial flushing, and redness and swelling on the olfactory organ or cheeks (rosacea). Treatment involves eyelid hygiene (cleansing with a mild soap, such as diluted babe shampoo, or centre scrub solution), gentle chapeau massage, and warm compresses. This regimen should continue indefinitely. Topical erythromycin or bacitracin ophthalmic ointment practical to eyelids may exist used in patients who do not respond to eyelid hygiene. Azithromycin eye drops may also exist used in the treatment of blepharitis. In severe cases, prolonged use of oral antibiotics (doxycycline or tetracycline) may be beneficial.33 Topical steroids may also be useful for severe cases.30
CORNEAL ABRASION
Corneal abrasion is diagnosed based on the clinical presentation and middle examination. If needed, short-term topical anesthetics may be used to facilitate the eye test. Fluorescein staining under a cobalt bluish filter or Wood lamp is confirmatory. A branching design of staining suggests HSV infection or a healing abrasion. HSV infection with corneal involvement warrants ophthalmology referral within one to two days. In patients with corneal abrasion, it is proficient practise to bank check for a retained foreign body under the upper eyelid.
Treatment includes supportive intendance, cycloplegics (atropine, cyclopentolate [Cyclogyl], homatropine, scopolamine, and tropicamide), and pain control (topical nonsteroidal anti-inflammatory drugs [NSAIDs] or oral analgesics). The need for topical antibiotics for uncomplicated abrasions has non been proven. Topical aminoglycosides should exist avoided because they are toxic to corneal epi-thelium.34 Studies show that eye patches do not amend patient comfort or healing of corneal chafe.35 All steroid preparations are contraindicated in patients with corneal abrasion. Referral to an ophthalmologist is indicated if symptoms worsen or exercise non resolve within 48 hours.
SUBCONJUNCTIVAL HEMORRHAGE
Subconjunctival hemorrhage is diagnosed clinically. Information technology is harmless, with blood reabsorption over a few weeks, and no handling is needed. Warm compresses and ophthalmic lubricants (eastward.m., hydroxypropyl cellulose [Lacrisert], methylcellulose [Murocel], artificial tears) may salve symptoms. If hurting is present, a cause must be identified. It is good practice to check for corneal involvement or penetrating injury, and to consider urgent referral to ophthalmology. Recurrent hemorrhages may require a workup for bleeding disorders. If the patient is taking warfarin (Coumadin), the International Normalized Ratio should be checked.
EPISCLERITIS
Episcleritis is a localized area of inflammation involving superficial layers of episclera. Information technology is normally cocky-limiting (lasting upwardly to iii weeks) and is diagnosed clinically. Investigation of underlying causes is needed merely for recurrent episodes and for symptoms suggestive of associated systemic diseases, such as rheumatoid arthritis. Treatment involves supportive care and utilize of artificial tears. Topical NSAIDs take not been shown to have significant benefit over placebo in the treatment of episcleritis.36 Topical steroids may be useful for severe cases. Ophthalmology referral is required for recurrent episodes, an unclear diagnosis (early scleritis), and worsening symptoms.
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Source: https://www.aafp.org/afp/2010/0115/p137.html