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Three Part Question

In [a patient with episcleritis] [do oral NSAIDS] [reduce signs and symptoms]

Clinical Scenario

A 34-year old lady presents to the Emergency Eye Centre with a recurrent episode of a painful red left eye. You diagnose episcleritis and wonder whether steroid eye drops might be indicated in this particular case. The very experienced Emergency Eye Nurse Practitioner, however, discusses various treatment options with the patient. These are:
a) No treatment
b) Artificial tears
c) Steroid eye drops
d) Oral NSAIDS
You wonder how much evidence there is for option d).

Search Strategy

[(exp Analgesics, Non-Narcotic/ or analgesics.mp. or exp Analgesics/) OR (NSAIDS.mp or exp Anti-Inflammatory Agents, Non-Steroidal/) OR (anti-inflammatory agents, non-steroidal.mp. or exp Anti-Inflammatory Agents, Non-Steroidal/) OR (Non-Steroidal Anti-Inflammatory Agents.mp. or exp Anti-Inflammatory Agents, Non-Steroidal/) OR (exp Anti-Inflammatory Agents/ or exp Anti-Inflammatory Agents, Non-Steroidal/ or Non-Steroidal Anti-Inflammatory Drugs.mp. or exp Cyclooxygenase Inhibitors/) OR (anti-inflammatory agents.mp. or exp Anti-Inflammatory Agents/) OR (exp Anti-Inflammatory Agents/ or exp Anti-Inflammatory Agents, Non-Steroidal/ or anti-inflammatory drugs.mp.) OR (anti-inflammatory$.tw.) OR (NSAID$.tw.) OR (ibuprofen.mp. or exp Ibuprofen/) OR ('Brufen'.mp. or exp Ibuprofen/) OR (exp Ibuprofen/ or 'Fenbid'.mp.) OR (Aceclofenac.mp.) OR (Acemetacin.mp.) OR ('Emflex'.mp.) OR (Celecoxib.mp.) OR ('Celebrex'.mp.) OR (Dexketoprofen.mp.) OR (Diclofenac.mp. or exp Diclofenac/) OR (Diclofenac Sodium.mp. or exp Diclofenac/) OR ('Voltarol'.mp. or exp Diclofenac/) OR (Diflunisal.mp. or exp Diflunisal/) OR ('Dolobid'.mp. or exp Diflunisal/) OR (Etodolac.mp. or exp Etodolac/) OR ('Lodine'.mp. or exp Etodolac/) OR (Etoricoxib.mp.) OR ('Arcoxia'.mp.) OR (Fenbufen.mp.) OR ('Lederfen'.mp.) OR (Fenoprofen.mp. or exp Fenoprofen/) OR (Flurbiprofen.mp. or exp Flurbiprofen/) OR ('Froben'.mp. or exp Flurbiprofen/) OR (Indometacin.mp. or exp Indomethacin/) OR (Indomethacin.mp. or exp Indomethacin/) OR (exp Indomethacin/ or 'Flexin'.mp.) OR (Ketoprofen.mp. or exp Ketoprofen/) OR ('Orudis'.mp. or exp ketoprofen/) OR (exp Ketoprofen/ or 'Oruvail'.mp.) OR (Mefenamic Acid.mp. or exp Mefenamic Acid/) OR (exp Mefenamic Acid/ or mefanamic Acid.mp.) OR ('Ponstan'.mp. or exp Mefenamic Acid/) OR (Meloxicam.mp.) OR ('Mobic'.mp.) OR (Nabumetone.mp.) OR ('Relifex'.mp.) OR (Naproxen.mp. or exp Naproxen/) OR ('Naprosyn'.mp. or exp Naproxen/) OR ('Synflex'.mp. or exp Naproxen/) OR (Piroxicam.mp. or exp Piroxicam/) OR ('Feldene'.mp. or exp Piroxicam/) OR (Sulindac.mp. or exp Sulindac/) OR ('Clinoril'.mp. or exp Sulindac/) OR (Tenoxicam.mp.) OR ('Mobiflex'.mp.) OR (Tiaprofenic Acid.mp.) OR ('Surgam'.mp.) OR (Phenylbutazone.mp. or exp Phenylbutazone/) OR (Oxyphenbutazone.mp. or exp Oxyphenbutazone/) OR (Aspirin.mp. or exp Aspirin/)] AND [(episcleritis.mp. or exp Scleritis) OR (exp Scleritis/ or episcleritis-scleritis.mp.) OR (exp Scleritis/ or nodular episcleritis.mp.)]
LIMIT to English Language
Ovid Medline 1966 - May Week 4 2006
Embase 1980 - 2006 Week 22

Search Outcome

Medline yielded 146 papers, only 1 of which was relevant to the three-part question.
Of 415 papers from Embase, none answered the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Watson PG, Lobascher DJ et al 1966, Aug UK	59 patients with deteriorating or recurrent episcleritis despite previous local steroid therapy. Stratified randomisation was carried out on entry. 30 patients (35 eyes) were given oxyphenbutazone; 29 patients (39 eyes) were given prednisolone.	RCT Outcomes: 1) Pain; 2) Flare; 3) Keratic precipitates; 4) Cells; 5) Episcleral injection; 6) Conjunctival injection; 7) Keratitis (type); 8) Keratitis (degree); 9) Scleral thinning; 10) Nodules Patients were assessed weekly for 4 weeks then fortnightly until 56 days.	Pain	The P group had greater resolution of pain in the first 3 weeks, but after this the O group had less pain (NS).	No control group. Small study with no sample size estimate. Likely to be some subjectivity in grading of outcome measures. Inadequate description of methods and no Table 1 given. No explanation of statistics. Results presented graphically and with percentages rather than raw figures. 15 patients were withdrawn from trial and their results not included.
			Episcleral injection	The P group improved markedly in the 3rd week then deteriorated rapidly, whilst the O group continued to improve from the 3rd week onwards (NS).
			Improvement in conjunctival injection during the first 7 days	50% of the O group and 75% of the P group improved (Significant).
			Nodules	More marked regression of nodules in the P group in the first 7 days, but regressed in the last weeks of the trial. The effect of the O was slower but more persistent and complete.

Comment(s)

There are considerable weaknesses in this paper.

Clinical Bottom Line

There is very little evidence to support the use of oral NSAIDS in the treatment of episcleritis.

References

1. PG Watson, DJ Lobascher, DW Sabiston, E Lewis-Faning, PD Fowler & BR Jones Double-blind trial of the treatment of episcleritis-scleritis with oxyphenbutazone or prednisolone British Journal of Ophthalmology Aug 1966 (50): 463 - 81