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Episcleritis: Causes, Symptoms and Treatment

Episcleritis is an inflammation of the episclera, the thin tissue layer between the conjunctiva and the white of the eye. It causes visible redness and is usually benign.

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Things worth knowing about "Episcleritis"

Episcleritis is an inflammation of the episclera, the thin tissue layer between the conjunctiva and the white of the eye. It causes visible redness and is usually benign.

What is Episcleritis?

Episcleritis is an inflammation of the episclera – a thin layer of connective tissue located between the transparent conjunctiva and the white outer coat of the eye, known as the sclera. The condition typically presents as a clearly visible, sectoral or diffuse redness of the eye and is, in most cases, self-limiting, meaning it resolves without specific treatment. Unlike the deeper and more serious scleritis, episcleritis is generally not associated with significant pain and does not usually threaten vision.

Types of Episcleritis

There are two main forms of episcleritis:

Simple (simplex) episcleritis: The more common type, characterised by a localised red patch on the surface of the eye. It typically resolves within one to two weeks.
Nodular episcleritis: Characterised by a raised, inflammatory nodule on the ocular surface. This form tends to last longer and is more likely to recur.

Causes

In many cases, the exact cause of episcleritis remains unknown (idiopathic). However, in a proportion of patients the condition is associated with an underlying systemic disease, including:

Rheumatoid arthritis
Systemic lupus erythematosus (SLE)
Crohn's disease and ulcerative colitis (inflammatory bowel diseases)
Gout (hyperuricaemia)
Infectious diseases such as herpes zoster or tuberculosis
Sarcoidosis

When episodes are recurrent or bilateral, a systemic workup should be considered to rule out an underlying condition.

Symptoms

The typical signs and symptoms of episcleritis include:

Sectoral or diffuse redness of one or both eyes
Mild burning or a foreign body sensation
Mild light sensitivity (photophobia)
Mild to moderate watering of the eye
Little or no tenderness on gentle palpation of the eyeball

Severe eye pain, a decrease in visual acuity, or a deep, dark-red to violaceous hue of the redness are warning signs that may indicate the more serious condition of scleritis and require prompt ophthalmological assessment.

Diagnosis

The diagnosis is primarily clinical and established by an ophthalmological examination:

Slit-lamp examination: Allows the ophthalmologist to assess the depth and extent of inflammation. In episcleritis, the inflammation is superficial and the engorged vessels blanch with a drop of phenylephrine (a vasoconstrictive agent) – an important distinguishing feature from scleritis, in which blanching does not occur.
Blood tests may be ordered if an underlying systemic condition is suspected (e.g. rheumatological markers, uric acid levels, inflammatory parameters such as CRP).

Treatment

Mild cases of episcleritis often require no specific treatment and resolve spontaneously. For more troublesome symptoms, the following options are available:

Artificial tears (eye drops): To relieve burning and the foreign body sensation.
Topical non-steroidal anti-inflammatory drugs (NSAIDs): Anti-inflammatory eye drops such as diclofenac can help reduce discomfort.
Topical corticosteroids: For more severe or nodular cases, the ophthalmologist may prescribe short-term corticosteroid eye drops. These should only be used under medical supervision.
Systemic treatment: If an underlying systemic condition is identified, treating that condition is the primary goal, as it frequently leads to improvement of the ocular inflammation as well.

Prognosis and Outlook

The prognosis of episcleritis is generally favourable. Most episodes resolve completely within one to four weeks. Recurrences are possible, particularly in patients with an underlying systemic disease or in the nodular form of the condition. Permanent visual impairment is very rarely associated with episcleritis and occurs almost exclusively when the diagnosis is incorrect and scleritis is actually present.

References

Pavesio C.E., Meier F.M.: Systemic disorders associated with episcleritis and scleritis. Current Opinion in Ophthalmology, 2001; 12(6): 471-478.
Jabs D.A., Mudun A., Dunn J.P., Marsh M.J.: Episcleritis and scleritis: clinical features and treatment results. American Journal of Ophthalmology, 2000; 130(4): 469-476.
Bowling B.: Kanski's Clinical Ophthalmology: A Systematic Approach. 8th edition. Elsevier, 2016.

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