> Table of Contents > Episcleritis
Episcleritis
Sean M. Oser, MD, MPH
Tamara K. Oser, MD
image BASICS
  • Episcleritis is the localized inflammation of the vascular connective tissue superficial to the sclera.
  • Usually a self-limited condition, typically resolving within 3 weeks
  • Most cases resolve without treatment.
  • Topical lubricants and/or topical corticosteroid treatment may relieve symptoms while awaiting spontaneous resolution.
DESCRIPTION
  • Edema and injection confined to the episcleral tissue
  • Two types
    • Simple (diffuse scleral involvement—more common)
    • Nodular (focal area[s] of involvement—less common)
EPIDEMIOLOGY
Slight female predominance (˜60-65%)
Incidence
  • May occur at any age
  • Peak incidence in 40s to 50s
  • Community incidence not well-known (˜20 to 50 cases/100,000 person-years)
Prevalence
Not historically well-known; a recent community study found a prevalence of 53 cases/100,000 persons.
ETIOLOGY AND PATHOPHYSIOLOGY
Etiology: Usually idiopathic, but other causes may be found (either nonimmune or immune).
Pathophysiology
  • Nonimmune (e.g., dry eye syndrome, with histology showing widespread vasodilation, edema, lymphocytic infiltration)
  • Immune (systemic vasculitis or rheumatologic disease)
COMMONLY ASSOCIATED CONDITIONS
  • Usually not associated with another condition
  • Less commonly associated conditions include the following:
    • Rheumatoid arthritis
    • Vasculitis
    • Inflammatory bowel disease
    • Ankylosing spondylitis
    • Systemic lupus erythematosus
    • Gout
    • Herpes zoster
    • Hypersensitivity disorders
      • Rosacea
      • Contact dermatitis
      • Penicillin sensitivity
      • Erythema multiforme
image DIAGNOSIS
Episcleritis is a clinical diagnosis (1,2)[C].
PHYSICAL EXAM
  • Check visual acuity; decreased vision is very unusual with episcleritis, and its presence should raise suspicion for another condition such as scleritis (1,2,3)[C].
  • Focal hyperemia (2,4)[C]
  • Pupils equal and reactive (2)[C]
  • Superficial episcleral vascular dilation (1,2)[C]
  • Episcleral edema (1,2)[C]
    • Diffuse in simple episcleritis
    • Focal in nodular episcleritis
  • Tenderness over involved area may be present (2)[C] but is usually absent (3,4)[C].
  • Superficial episcleral vascular hyperemia blanches with topical phenylephrine (1,4)[C].
DIFFERENTIAL DIAGNOSIS
  • Scleritis
  • Bacterial conjunctivitis
  • Viral conjunctivitis
  • Herpes (ulcerative) keratitis
  • Superficial keratitis
  • Increased intraocular pressure (ocular hypertension)
DIAGNOSTIC TESTS & INTERPRETATION
Most patients with episcleritis do not require any further lab work or diagnostic studies (5)[C].
image TREATMENT
MEDICATION
Treatment for episcleritis typically consist of symptomatic relief. The goal is to suppress the inflammation, which will, in turn, relieve the discomfort or pain. In most cases, treatment is not needed.
First Line
Topical lubricants such as artificial tears are typically used for initial management of symptomatic episcleritis (2)[C].
Second Line
  • Topical corticosteroids are useful when discomfort is not sufficiently controlled by conservative measures (2,5,6)[C].
    • Fluorometholone 0.1% drops 4 times daily; if not effective, may increase frequency
    • Prednisolone 0.5-1% eye drops
  • Refractory episcleritis may be treated with oral NSAIDs, typically indomethacin 25 mg 3 or 4 times daily (5)[C].
P.353

ISSUES FOR REFERRAL
Recurrent episodes, uncertain diagnosis, and/or worsening symptoms should prompt ophthalmology referral. Rarely, episcleritis may progress to scleritis in which case ophthalmology referral is also recommended.
ADDITIONAL THERAPIES
  • Topical NSAIDs have not been shown to have a significant benefit over artificial tears (7)[B].
  • When episcleritis results from viral infection, appropriate antiviral therapy is indicated (6)[C].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Episcleritis is usually self-limited (up to 21 days) and does not typically require follow-up.
PROGNOSIS
  • Most patients have no ocular complications.
  • Prognosis for episcleritis is excellent, with most patients making a full recovery.
REFERENCES
1. Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA, et al. Clinical characteristics of a large cohort of patients with scleritis and episcleritis. Ophthalmology. 2012;119(1):43-50.
2. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010;81(2):137-144.
3. Garrity JA. Ocular manifestations of small-vessel vasculitis. Cleve Clin J Med. 2012;79(Suppl 3):S31-S33.
4. Galor A, Thorne JE. Scleritis and peripheral ulcerative keratitis. Rheum Dis Clin North Am. 2007;33(4):835-854.
5. Jabs DA, Mudun A, Dunn JP, et al. Episcleritis and scleritis: clinical features and treatment results. Am J Ophthalmol. 2000;130(4):469-476.
6. Berchicci L, Miserocchi E, Di Nicola M, et al. Clinical features of patients with episcleritis and scleritis in an Italian tertiary care referral center. Eur J Ophthalmol. 2014;24(3):293-298.
7. Williams CP, Browning AC, Sleep TJ, et al. A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis. Eye (Lond). 2005;19(7):739-742.
Additional Reading
&NA;
  • Homayounfar G, Borkar DS, Tham VM, et al. Clinical characteristics of scleritis and episcleritis: results from the Pacific Ocular Inflammation Study. Ocul Immunol Inflamm. 2014;22(5):403-404.
  • Homayounfar G, Nardone N, Borkar DS, et al. Incidence of scleritis and episcleritis: results from the Pacific Ocular Inflammation Study. Am J Ophthalmol. 2013;156(4):752-758.
  • Honik G, Wong IG, Gritz DC. Incidence and prevalence of episcleritis and scleritis in Northern California. Cornea. 2013;32(12):1562-1566.
Codes
&NA;
ICD10
  • H15.109 Unspecified episcleritis, unspecified eye
  • H15.129 Nodular episcleritis, unspecified eye
  • H15.102 Unspecified episcleritis, left eye
Clinical Pearls
&NA;
  • Episcleritis typically is a benign, self-limited disorder.
  • Is often not painful and presents without decrease in visual acuity
  • Although treatment is often not needed, when employed, the goal is symptomatic relief while awaiting spontaneous resolution.
  • Topical lubricants and/or topical corticosteroid treatment may relieve symptoms.
  • Associated complications are uncommon and not severe but may include anterior uveitis, decreased vision, and ocular hypertension.
  • Episcleritis can be an early presentation of scleritis, which is more severe. Accurate diagnosis of episcleritis is important.