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Episcleritis
Episcleritis
Episcleritis
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Episcleritis
Eye with Episcleritis
SpecialtyOphthalmology
SymptomsPhotophobia, hot/prickly/gritty sensation in eye,[1] Eye redness without pain, Watery eyes
TypesNodular and simple/diffuse
Diagnostic methodHistory and physical examination
Differential diagnosisScleritis, Pinguecula
TreatmentArtificial tears, supportive care
MedicationTopical corticosteroids
Non-steroidal anti-inflammatory drugs.
PrognosisGood

Episcleritis is a benign, self-limiting inflammatory disease affecting part of the eye called the episclera. The episclera is a thin layer of tissue that lies between the conjunctiva and the connective tissue layer that forms the white of the eye (sclera). Episcleritis is a common condition, and is characterized by the abrupt onset of painless eye redness.

There are two types of episcleritis, nodular and simple. Nodular episcleritis lesions have raised surface. Simple episcleritis lesions are flat. There are two subtypes. In diffuse simple episcleritis, inflammation is generalized. In sectoral simple episcleritis, the inflammation is restricted to one region.

Most cases of episcleritis have no identifiable cause, although about a third of cases are associated with various systemic diseases. Often people with episcleritis experience it recurrently. Treatment focuses on decreasing discomfort, and includes lubricating eye drops. More severe cases may be treated with topical corticosteroids or oral anti-inflammatory medications (NSAIDs).

Signs and symptoms

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Episcleritis of a 40 year old female

Symptoms of episcleritis typically include painless redness of the eye (mild pain is possible but atypical), and watery eyes.[2] The pain of episcleritis is typically mild, less severe than in scleritis,[3] and may be tender to palpation.[4]

There are two types of episcleritis: the diffuse type, where the redness involves the entire episclera, and the nodular type, where the redness appears more nodular, involving only a small, well-circumscribed area (sectoral).[5] The diffuse type of episcleritis may be less painful than the nodular type. Sometimes, small nodules are present within the episclera, which move slightly over the sclera with gentle pressure.[5]

Discharge is absent with episcleritis, and vision is unaffected.[5] Patients with episcleritis experience far less photophobia than patients with uveitis.[2] Episcleritis does not cause the presence of cells or flare in the anterior chamber of the eye.[2] In 80 percent of cases, episcleritis affects only one eye,[6] whereas scleritis often affects both eyes.

Pathophysiology

[edit]

Episcleritis is caused by inflammation due to the activation of immune cells, including lymphocytes and macrophages.[6] In most cases, the cause of episcleritis is never determined (idiopathic). An identifiable cause is discovered in about one third of cases.[7] Several diseases are associated with episcleritis, including systemic vasculitis (polyarteritis nodosa, granulomatosis with polyangiitis, Behçet's disease), connective tissue diseases (rheumatoid arthritis, relapsing polychondritis, systemic lupus erythematosus),[8] psoriatic arthritis, ankylosing spondylitis, Cogan syndrome, rosacea, gout,[5] atopy,[7] Crohn's disease, and ulcerative colitis.[9][6] 59 percent of patients with relapsing polychondritis have either episcleritis or scleritis.[10] Rarely, episcleritis may be caused by scleritis.[11] Very rarely, episcleritis is associated with infections, including Lyme disease, tuberculosis, syphilis, and herpes zoster.[6]

The redness in the eye associated with episcleritis is due to engorgement of the large episcleral blood vessels, which run in a radial direction from the limbus.[5] Typically, there is no uveitis, or thickening of the sclera.

Diagnosis

[edit]

The diagnosis of episcleritis is based upon the history and physical examination. The history should be explored for the presence of the diseases associated with episcleritis, and the symptoms they cause, such as rash, arthritis, venereal disease, and recent viral infection.[5] Episcleritis may be differentiated from scleritis by using phenylephrine or neosynephrine eye drops, which causes blanching of the blood vessels in episcleritis, but not in scleritis.[3] A blue color to the sclera suggests scleritis, rather than episcleritis. After anesthetizing the eye with medication, the conjunctiva may be moved with a cotton swab to observe the location of the enlarged blood vessels.[citation needed] In very rare cases, if episcleritis does not respond to treatment, then a biopsy may be considered,[6] which help provide information regarding any underlying condition (granulomatosis with polyangitis, vasculitis, etc.). However, a biopsy is not routinely necessary in the diagnosis of episcleritis.[citation needed]

Treatment

[edit]

Often, treatment is not necessary, because episcleritis is a self-limiting condition. Artificial tears may be used to help with irritation and discomfort. More severe cases can be treated with either topical corticosteroids or oral non-steroidal anti-inflammatory drugs.[7]

Ketorolac, a topical NSAID, may be used, but it is not more effective than artificial tears and it causes more side effects.[12]

Prognosis

[edit]

Episcleritis is a benign, self-limiting condition, meaning patients recover without any treatment. Most cases of episcleritis resolve within 7–10 days.[2] The nodular type is more aggressive and takes longer to resolve.[2] Although rare, some cases may progress to scleritis.[13] However, in general, episcleritis does not cause complications in the eye.[13] Smoking tobacco delays the response to treatment in patients with episcleritis.[14]

Epidemiology

[edit]

While episcleritis is a common disease,[15] its exact prevalence and incidence are unknown.[6] It typically affects young[15] or middle aged women.[6] The diffuse form of episcleritis (70%) is more common than the nodular form (30%).[6] One retrospective study found 28 percent of individuals with episcleritis experienced recurrent episodes of the disease.[16]

References

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[edit]
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Episcleritis

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from Grokipedia
Episcleritis is an acute, benign inflammation of the episclera, the thin vascular layer of situated between the and the of the eye. It typically presents as localized or diffuse redness of the eye with mild discomfort, distinguishing it from more severe conditions like , and usually resolves spontaneously within 1 to 3 weeks without affecting vision. The condition is classified into two primary forms: simple episcleritis, which involves sectoral or diffuse vascular congestion without nodules and accounts for about 70% of cases, and nodular episcleritis, characterized by a raised, tender nodule in approximately 30% of instances. Episcleritis most commonly affects young to middle-aged adults, with a higher in females, and has an estimated annual incidence of 41.0 cases per 100,000 individuals and a of 52.6 per 100,000. While the is idiopathic in the majority of cases, it is associated with systemic conditions in 26% to 36% of patients, including autoimmune disorders such as , , and , as well as less frequently with infections like herpes zoster or . Pathophysiologically, it involves non-granulomatous and congestion of the superficial episcleral vascular plexus, sparing the deeper scleral layers, and may recur in up to 30% of affected individuals. Clinically, patients experience unilateral or bilateral ocular redness, mild to moderate pain or tenderness upon , and occasional , but rarely discharge, discharge, or significant vision impairment. is primarily clinical, relying on slit-lamp examination to identify the characteristic injection pattern, with a phenylephrine blanching test used to confirm superficial involvement by causing the redness to fade, unlike in . Systemic evaluation, including blood tests for autoimmune markers like (ANA) or (), is recommended if underlying disease is suspected. Treatment is often conservative, with and cool compresses sufficient for mild cases; topical corticosteroids (e.g., 0.1%) or oral nonsteroidal anti-inflammatory drugs (e.g., ibuprofen 400-800 mg three times daily) may be employed for symptomatic relief, though complications such as secondary or corneal dellen are uncommon. Overall, episcleritis carries an excellent prognosis with rare long-term sequelae when managed appropriately.

Background

Definition and Classification

Episcleritis is defined as a benign, self-limited inflammatory condition affecting the episclera, the thin, vascular layer of situated between the and the . The episclera consists of fibroelastic tissue with a rich vascular supply derived from the , forming superficial and deep plexuses that contribute to its characteristic mobility and loose attachment to the underlying , which facilitates easy blanching of its vessels with vasoconstrictors. This superficial location distinguishes it anatomically from deeper ocular structures, allowing the inflammation to remain confined without typically threatening visual function. Episcleritis is classified into two primary subtypes based on the pattern of involvement: simple episcleritis and nodular episcleritis. Simple episcleritis, which accounts for the majority of cases (approximately 70 to 84 percent), manifests as diffuse or sectoral hyperemia involving the episcleral vessels without the formation of nodules. In contrast, nodular episcleritis, comprising about 16 to 30 percent of cases, features a localized, elevated inflammatory nodule that is mobile over the due to the episclera's loose attachment. These subtypes reflect variations in the inflammatory process but share the condition's generally favorable . A key distinction exists between episcleritis and , the latter involving deeper inflammation of the itself, which is more severe and often associated with systemic autoimmune disorders. Unlike episcleritis, affects non-blanchable scleral vessels and carries a higher risk of ocular complications. While episcleritis is typically idiopathic, it may occasionally be linked to underlying systemic diseases, though such associations are explored further in discussions of .

Epidemiology

Episcleritis has an estimated incidence of 41.0 per 100,000 person-years and a of 52.6 per 100,000 individuals, based on a population-based study in . These rates indicate that episcleritis is a relatively uncommon ocular inflammatory condition compared to more frequent causes of eye redness, such as . The condition demonstrates a clear demographic skew, with females comprising 60% to 70% of cases, yielding a female-to-male ratio of approximately 2:1. The peak age of onset occurs in young to middle-aged adults, typically between 20 and 40 years, though the mean age at is around 40 to 45 years across studies. Incidence rates are highest among females aged 45 to 64 years, at 74.0 per 100,000 person-years. Demographic factors include female sex; may delay treatment efficacy and exacerbate inflammatory responses. Episcleritis is also associated with autoimmune conditions, particularly , though detailed mechanisms are explored elsewhere. Studies indicate no strong racial or geographic predilections, with incidence variations largely attributable to population demographics rather than .

Clinical Presentation

Signs and Symptoms

Episcleritis typically manifests with acute sectoral or diffuse redness of the eye, often accompanied by mild ocular discomfort or irritation that is rarely severe. Patients may also experience tearing and occasional , though these are not prominent features. Visual acuity remains normal, and there is no associated discharge. On examination, objective signs include localized or diffuse injection of the episcleral vessels, which appear as prominent, tortuous radial vessels overlying the , with mild tenderness to . These findings are visible without in most cases and do not impair vision. Episcleritis can be differentiated into simple (diffuse) and nodular forms based on the presence of a localized elevated nodule in the latter. The condition is self-limited, with the simple form typically resolving within 7-10 days and the nodular form taking 5-6 weeks. Bilateral involvement occurs in up to one-third of cases.

Types

Episcleritis is classified into two main subtypes: simple episcleritis and nodular episcleritis, distinguished primarily by their clinical appearance and course. Simple episcleritis, the more common form accounting for approximately 70% to 80% of cases, is characterized by transient sectoral or diffuse hyperemia of the episcleral vessels without nodule formation. It typically presents with mild symptoms such as redness and slight discomfort, resolving within 1 to 2 weeks, and is often idiopathic in nature. Nodular episcleritis, comprising about 20% to 30% of cases, features a distinct, tender, elevated nodule of inflamed episcleral tissue, accompanied by more persistent redness and that may last 2 to 6 weeks. This subtype tends to have a gradual onset and greater discomfort compared to the simple form, with association with underlying systemic diseases, such as or other autoimmune conditions, in up to one-third of overall episcleritis cases. A key clinical distinction between the subtypes lies in their vascular response and potential to mimic deeper ; both simple and nodular episcleritis typically blanch with topical 2.5% to 10% due to superficial vessel involvement, helping differentiate them from , though the nodular form's raised may occasionally suggest more severe . Recurrence occurs in about 25% to 30% of episcleritis patients overall, but is more common and frequent in the nodular subtype.

Etiology and Pathophysiology

Etiology

Episcleritis is idiopathic in the majority of cases, with approximately 64% to 74% lacking an identifiable cause. In the remaining instances, it is frequently associated with underlying systemic autoimmune or inflammatory conditions, accounting for 26% to 36% of cases overall. is the most common associated systemic condition, while other conditions include (such as and ) and . Nodular episcleritis, in particular, shows a higher prevalence of these systemic links compared to diffuse forms. Infectious etiologies are rare but documented, typically involving bacterial, viral, or mycobacterial pathogens. Examples include herpes zoster virus, syphilis (Treponema pallidum), and tuberculosis (Mycobacterium tuberculosis), which may trigger episcleritis through direct ocular involvement or systemic dissemination. Additional triggers encompass medication-induced reactions, ocular trauma, and postoperative inflammation. Certain drugs, such as the antiepileptic topiramate and the bisphosphonate pamidronate, have been implicated in episcleritis onset, often resolving upon discontinuation. Recent studies from 2020 to 2025 have also reported associations with COVID-19 infection and vaccination, including reports of recurrent nodular episcleritis as a manifestation of long COVID, suggesting a possible immune-mediated response to SARS-CoV-2. No clear genetic predisposition has been identified, though an immune-mediated hypersensitivity mechanism is proposed as underlying many cases.

Pathophysiology

Episcleritis represents an immune-mediated, non-granulomatous inflammatory process primarily affecting the vascular network within the episclera, the thin layer between the and . This involves the activation and infiltration of resident immune cells, including lymphocytes and macrophages, which contribute to localized tissue reactivity. The process is often triggered by underlying autoimmune conditions, such as , where dysregulated immune responses target ocular tissues. Key inflammatory mediators, including pro-inflammatory cytokines, are released by these infiltrating cells, promoting and increased permeability of episcleral vessels. This leads to vascular congestion and interstitial edema within the superficial episcleral , manifesting as localized swelling without extension to deeper structures. The episclera's loose attachment to the underlying facilitates this superficial involvement, confining the inflammatory changes to the more accessible vascular layer supplied by the . The condition's self-limiting nature stems from endogenous immune regulatory mechanisms that downregulate the inflammatory response, typically leading to spontaneous resolution within 1 to 3 weeks without progression to chronicity or . In contrast to , episcleritis spares the avascular scleral stroma and deeper tissues, thereby avoiding destructive features such as , thinning, or uveal involvement.

Diagnosis

Diagnostic Approach

The diagnostic approach to episcleritis begins with a detailed patient history to characterize the onset, duration, and associated features of the condition. Patients typically report an acute onset of unilateral or bilateral ocular redness, often sectoral, with mild discomfort or tenderness but minimal or changes; episodes typically last 1 to 3 weeks and may recur. Inquiry into systemic symptoms, such as joint pain, , or gastrointestinal issues, is essential to identify potential underlying autoimmune associations, while a review of recent medication use can help exclude drug-induced causes. Physical examination relies on external and slit-lamp biomicroscopy to evaluate the and pattern of vascular injection. External exam reveals localized or diffuse redness with possible mild eyelid or conjunctival , but without significant tenderness on ; slit-lamp assessment uses a narrow beam to confirm superficial episcleral involvement, where the outer reflection is displaced while the inner scleral reflection remains undisturbed, distinguishing it from deeper . A key confirmatory test is the instillation of topical drops (2.5% to 10%), which causes blanching of the superficial episcleral vessels within 10 to 15 minutes if episcleritis is present, due to of the involved plexus; failure to blanch suggests or other deeper pathology. Laboratory tests and imaging are not routinely required for isolated episodes but are indicated if recurrent disease or systemic symptoms suggest an underlying etiology, such as ; in these cases, serologic evaluation including (ANA), rheumatoid factor, and may be pursued, along with targeted tests like for spondyloarthropathies.

Differential Diagnosis

Episcleritis must be differentiated from other causes of red eye to avoid misdiagnosis, as some mimics require urgent intervention or systemic evaluation. Key distinguishing features include the localized, sectoral injection in episcleritis, mild discomfort without vision changes, and blanching of the involved vessels with topical (distinguishing it from , where redness persists), though the injection pattern and vessel mobility help differentiate from . Conjunctivitis presents with more diffuse conjunctival injection, often accompanied by , itching, or sensation, and the redness blanches completely with application. In contrast, episcleritis involves deeper episcleral vessels with minimal discharge and sectoral redness that moves with conjunctival manipulation. Viral or bacterial etiologies are common in conjunctivitis, while episcleritis is typically idiopathic or associated with . Scleritis is a critical mimic due to its potential for vision-threatening complications and association with systemic autoimmune disorders. It causes deeper, boring ocular exacerbated by , tenderness on palpation, and no blanching with , distinguishing it from episcleritis. Anterior scleritis subtypes include diffuse (widespread redness), nodular (elevated lesions), and necrotizing (with scleral thinning), while posterior scleritis involves choroidal features like ; episcleritis lacks these deeper involvements and systemic implications. Other conditions include pingueculitis, which is localized inflammation confined to an existing —a yellowish conjunctival nodule—causing focal redness and irritation without the broader sectoral involvement of episcleritis. (iritis) features ciliary flush, significant photophobia, blurred vision, and possible pupillary abnormalities, often with anterior chamber cells on slit-lamp exam, unlike the superficial, avascular presentation of episcleritis. manifests with systemic signs such as fever, proptosis, eyelid swelling, and restricted eye movements, representing a that requires and antibiotics, in opposition to the isolated ocular findings in episcleritis. Red flags warranting immediate referral include vision loss, severe or disproportionate pain, history of ocular trauma, or signs suggesting deeper involvement like corneal haze or , as these may indicate , , or infection rather than benign episcleritis. Episcleritis has been reported as a rare manifestation associated with infection (as noted in early 2020s case reports), such as or mild episcleritis itself; however, COVID-related cases often coincide with systemic symptoms and resolve similarly to idiopathic episcleritis without severe vision threat.

Management

Non-Pharmacological Treatment

Non-pharmacological management of episcleritis focuses on supportive measures to alleviate symptoms and promote resolution, particularly in mild cases where is self-limited. Cool compresses applied to the affected eye several times daily can reduce discomfort and by constricting blood vessels in the episclera. Preservative-free lubricating eye drops, such as , provide relief from dryness and irritation; refrigerating them before use enhances their soothing effect, with application recommended 4–6 times daily. These measures are especially suitable for mild symptoms, which often resolve spontaneously within 1 to 3 weeks without intervention. Patients should avoid rubbing the eyes to prevent exacerbation of inflammation and potential secondary complications. Discontinuing contact lens wear during episodes is advised to minimize irritation from mechanical trauma or poor fit, and exposure to environmental irritants such as smoke or dust should be limited. In uncomplicated cases, close observation is appropriate, with most episodes resolving without further action. Patient education emphasizes recognizing signs of recurrence, such as persistent redness or increased pain, and promptly seeking evaluation if symptoms worsen or do not improve within 1 to 2 weeks.

Pharmacological Treatment

The pharmacological treatment of episcleritis primarily focuses on alleviating symptoms and reducing , with over-the-counter oral nonsteroidal anti-inflammatory drugs (NSAIDs) serving as the first-line therapy for mild to moderate cases involving pain or discomfort. Typical over-the-counter regimens include ibuprofen at 200–400 mg every 6–8 hours as needed, taken with food to mitigate gastrointestinal side effects, or naproxen at 220 mg every 8–12 hours for a similar duration. For more severe symptoms, higher doses such as ibuprofen at 400-800 mg three times daily or naproxen at 250-500 mg twice daily may be prescribed. These agents are effective in resolving in most patients, with response typically observed within days, and therapy tapered based on symptom improvement to prevent recurrence. For persistent or refractory symptoms despite oral NSAIDs, topical options are employed, starting with lubricant eye drops such as applied four times daily to provide symptomatic relief and protect the ocular surface. If lubrication alone is insufficient, weak topical corticosteroids like 0.1% or etabonate 0.5% may be instilled four times daily for 1-2 weeks, followed by gradual tapering to minimize risks such as elevated . Topical NSAID drops, such as 0.5%, can also be used as an alternative or adjunct, applied similarly, though they may cause transient stinging. Stronger steroids, such as 1%, are generally avoided due to the potential for complications like and formation, reserved only for severe cases under specialist supervision. In episcleritis associated with underlying systemic conditions, such as , treatment targets the primary disease alongside ocular therapy; for instance, disease-modifying antirheumatic drugs (DMARDs) like are optimized to control and prevent recurrences. If an infectious is identified—though rare—appropriate systemic antibiotics are administered based on the suspected pathogen, such as for chlamydial associations. Recent guidelines, updated in 2025, reinforce prioritizing NSAIDs over corticosteroids to reduce complication risks while ensuring close monitoring for response and side effects in all pharmacological interventions.

Outcomes

Prognosis

Episcleritis generally carries an excellent prognosis, as it is a benign, self-limited inflammatory condition that resolves without long-term sequelae in the vast majority of cases. Most episodes, particularly simple episcleritis, resolve spontaneously within 2 to 3 weeks, while the nodular variant may persist slightly longer, often up to 4 weeks. In uncomplicated cases, there is no impact on visual acuity, and the condition does not lead to scarring or permanent ocular damage. Recurrence occurs in approximately 15% to 30% of patients, with episodes potentially affecting the same or contralateral eye and becoming less frequent over time. The rate of recurrence is higher in cases associated with underlying systemic diseases, such as or other autoimmune conditions, compared to idiopathic presentations. Idiopathic episcleritis tends to follow a more rapid and straightforward course to resolution than cases linked to systemic etiologies, which may experience prolonged inflammation or multiple flares. Although supportive treatments like topical lubricants or agents can accelerate symptom relief, the overall favorable outcome remains consistent even without intervention.

Complications

Episcleritis is generally a benign condition, but rare complications can arise, particularly in recurrent or nodular forms. Prolonged use of topical corticosteroids, a common treatment for persistent cases, carries risks of steroid-induced complications such as elevated leading to or the development of cataracts. These adverse effects are infrequent but emphasize the need for monitoring during extended therapy. In patients with underlying systemic diseases, such as , episcleritis may occur even with mild or absent disease activity, but appropriate management of the systemic condition is essential to prevent broader complications. Ocular complications in severe or recurrent episcleritis may include corneal involvement, observed in about 15% of cases, potentially leading to inflammatory infiltrates or . Typically, however, episcleritis does not result in vision loss.

References

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  3. https://eyewiki.org/Episcleritis
  4. https://emedicine.medscape.com/article/1228246-overview
  5. https://www.uptodate.com/contents/episcleritis
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  7. https://pubmed.ncbi.nlm.nih.gov/24145628/
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  12. https://pmc.ncbi.nlm.nih.gov/articles/PMC9781961/
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  14. https://pubmed.ncbi.nlm.nih.gov/10201593/
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  16. https://pmc.ncbi.nlm.nih.gov/articles/PMC5804772/
  17. https://www.rheumatologyadvisor.com/ddi/episcleritis/
  18. https://medlineplus.gov/ency/article/001019.htm
  19. https://www.allaboutvision.com/conditions/episcleritis/
  20. https://www.sciencedirect.com/science/article/pii/S2451993620302322
  21. https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2783653
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  24. https://pmc.ncbi.nlm.nih.gov/articles/PMC8156434/
  25. https://pmc.ncbi.nlm.nih.gov/articles/PMC3577924/
  26. https://www.reviewofoptometry.com/article/ro1117-a-red-eye-scleritis-or-episcleritis
  27. https://www.aafp.org/pubs/afp/issues/2010/0115/p137.html
  28. https://www.ncbi.nlm.nih.gov/books/NBK499944/
  29. https://www.aafp.org/pubs/afp/issues/2016/0615/p991.html
  30. https://home.hippoed.com/blog/differential-diagnosis-of-red-eye-when-to-refer-and-when-to-manage
  31. https://pmc.ncbi.nlm.nih.gov/articles/PMC8725430/
  32. https://www.sciencedirect.com/science/article/pii/S2162098924000045
  33. https://cchcs.ca.gov/wp-content/uploads/sites/60/Eye-Care-Referral-CG.pdf
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  35. https://pubmed.ncbi.nlm.nih.gov/34068884/
  36. https://pmc.ncbi.nlm.nih.gov/articles/PMC9977905/
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