Episcleritis

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Contents

Aetiology

Inflammation of the vascular connective tissue layer that lies between the sclera and conjunctiva

Predisposing factors

Incidence 41 per 100,000 per annum
Generally idiopathic, but up to one third of cases (especially nodular variety and in bilateral cases) associated with systemic disorders, e.g.

  • rheumatoid arthritis
  • inflammatory bowel disease
  • seronegative spondyloarthropathies, e.g. ankylosing spondylitis
  • vasculitides
  • systemic lupus erythematosus
  • relapsing polychondritis

(NB importance of careful history taking)
Previous history of episcleritis
Herpes Zoster Ophthalmicus
Commonest in 4th or 5th decades

Symptoms of episcleritis

Typically unilateral red eye, but bilateral in a quarter to a half of cases

  • Acute onset
  • Mild ache or burning sensation
  • Sometimes tender on palpation
  • Occasionally watery
  • Condition commonly recurrent

Signs of episcleritis

Hyperaemia from dilated episcleral vessels in one or more quadrants of one or both eyes. (Bilateral involvement suggests underlying systemic disease).
Hyperaemia blanches with vasoconstrictors (e.g. gutt. phenylephrine 2.5%)
Simple episcleritis (80%)

  • sectoral or diffuse redness
  • dilated episcleral vessels follow a regular radiating pattern and are largely immovable, unlike the finer overlying conjunctival vessels which move freely with the conjunctiva

Nodular episcleritis (20%)

  • nodule (mild elevation of the conjunctiva) with injection
  • in most cases, nodule within palpebral aperture
  • dilated episcleral vessels are moveable as the lesion is elevated

Typically no anterior chamber reaction
Usually no corneal or palpebral conjunctival involvement
No effect on visual acuity

Differential diagnosis

Scleritis (see Clinical Management Guideline on Scleritis)
Conjunctivitis (viral, bacterial, allergic)
Phlyctenular keratoconjunctivitis
Pingueculitis
Anterior uveitis

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological

Usually self-limiting in 7-10 days; nodular form may persist for longer
Reassurance: condition does not generally progress to more serious ocular disorder
Cold compresses
Advise patient to return/seek further help if symptoms persist
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

Pharmacological

Mild cases: no specific treatment
If discomfort: artificial tears as necessary for 1-2 weeks
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Inconsistent evidence for benefit of topical NSAIDs (off-licence use)
(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)

More severe cases (including nodular type) may need mild topical steroid e.g. fluorometholone or loteprednol for 1-2 weeks. A baseline measurement of IOP should be taken before starting steroid therapy
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Severe cases may benefit from systemic non-steroidal anti-inflammatory treatment, e.g. flurbiprofen 100mg or naproxen 500mg 
(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)

NB patients on topical steroids should be re-examined after 7-10 days (including repeat IOP measurement) (see Clinical Management Guideline on Steroid-related OHT and Glaucoma)

Management category

B3: management to resolution
B2 (modified): episcleritis with symptoms suggestive of systemic disease, or at second recurrence (third episode), refer for investigation
(Investigation: referral may vary between centres. It is possible that the GP may not have access to the range of blood tests required. May require rheumatology input)

Possible management by ophthalmologist

Investigation for underlying systemic disease

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation  (www.gradingworkinggroup.org)

Sources of evidence

Axmann S, Ebneter A, Zinkernagel MS. Imaging of the Sclera in Patients with Scleritis and Episcleritis using Anterior Segment Optical Coherence Tomography. Ocul Immunol Inflamm. 2016;24(1):29-34

Daniel Diaz J, Sobol EK, Gritz DC. Treatment and management of scleral disorders. Surv Ophthalmol. 2016;61(6):702-717

Lloyd-Jones D, Tokarewicz A, Watson PG. Clinical evaluation of clobetasone butyrate eye drops in episcleritis. Br J Ophthalmol. 1981;65(9):641-3

Lyons CJ, Hakin KN, Watson PG. Topical flurbiprofen: an effective treatment for episcleritis? Eye (Lond). 1990;4(3):521-5

Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA, Doctor PP, Tauber J, Foster CS. Clinical characteristics of a large cohort of patients with scleritis and episcleritis. Ophthalmology. 2012;119(1):43-50

Salama A, Elsheikh A, Alweis, R. Is this a worrisome red eye? Episcleritis in the primary care setting. J. Community Hosp. Intern. Med. Perspect. 2018;8(1):46-48

Watson PG, Lobascher DJ, Sabiston DW, Lewis-Faning E, Fowler PD, Jones BR. Double-blind trial of the treatment of episcleritis-scleritis with oxyphenbutazone or prednisolone. Br J Ophthalmol. 1966;50(8):463-81

Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol 1976;60:163-91

Williams CP, Browning AC, Sleep TJ, Webber SK, McGill JI. A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis. Eye (Lond). 2005;19(7):739-42

Plain language summary

Episcleritis is an inflammation of the episclera, the tissue that lies just under the outer skin of the white of the eye. Commonest between the ages of 40 to 60, it usually affects just one eye but both eyes are affected in a quarter to a half of cases. In about one in three of cases there is a background of inflammation elsewhere in the body, for example rheumatoid arthritis or inflammation of the bowel.

The condition begins without warning and patients experience redness, aching and tenderness of one or both eyes. The vision is not affected. Episcleritis may disappear in a week to ten days and return again later. The optometrist will reach a diagnosis based on the exact type of inflammation, which distinguishes this condition from conjunctivitis (inflammation of the outer skin of the eye) and scleritis (inflammation of the white part of the eyeball).

Cold compresses may relieve the symptoms, as may artificial tears in eye drop form. If the inflammation is more severe, steroid eye drops may be prescribed, and sometimes anti-inflammatory tablets are needed also.

After the second recurrence, the optometrist will normally refer the patient for investigation by the GP or ophthalmologist.

Episcleritis
Version 12
Date of search 12.09.21
Date of revision 25.11.21
Date of publication 21.04.22
Date for review 10.09.23
© College of Optometrists