Sharmini A. Balakrishnan, MD
Brad H. Feldman, M.D.,Sharmini A. Balakrishnan, MD,Russell W. Read, MD, PhD,Dr. Kabir Hossain,Erica Bernfeld M.D.,Bharat Gurnani MBBS,DNB,FCRS,FICO(UK), MRCS (Ed), MNAMS
Erica Bernfeld M.D.
Assigned status Update Pending
by Erica Bernfeld M.D. on January 18, 2022.
Episcleritis is a relatively common, benign, self-limited cause of red eye, due to inflammation of the episcleral tissues. There are two forms of this condition: nodular and simple. Nodular episcleritis is characterized by a discrete, elevated area of inflamed episcleral tissue. In simple episcleritis, vascular congestion is present in the absence of an obvious nodule.
A 2013 study estimated incidence of episcleritis as 41.0 per 100,000 per year and prevalence at 52.6. The simple variety is more common than nodular. According to one study, approximately sixty-seven percent of simple episcleritis is "sectoral" (involving only one sector or area of the episclera) and thirty-three percent is diffuse (involving the entire episclera).
Contents
- 1 Disease Entity
- 1.1 Disease
- 1.2 Etiology
- 1.3 Risk Factors
- 1.4 General Pathology
- 1.5 Pathophysiology
- 1.6 Primary prevention
- 2 Diagnosis
- 2.1 History
- 2.2 Physical examination
- 2.3 Signs
- 2.4 Symptoms
- 2.5 Clinical diagnosis
- 2.6 Diagnostic procedures
- 2.7 Laboratory test
- 2.8 Differential diagnosis
- 3 Management
- 3.1 General treatment
- 3.2 Medical therapy
- 3.3 Medical follow-up
- 3.4 Surgery
- 3.5 Complications
- 3.6 Prognosis
- 4 References
- H15.10 - Unspecified episcleritis
- H15.11 - Episcleritis periodica fugax
- H15.12 - Nodular episcleritis
Disease
Episcleritis is a relatively common, benign, self-limited inflammation of the episcleral tissues. There are two forms of this condition: nodular and simple. Nodular episcleritis is characterized by a discrete, elevated area of inflamed episcleral tissue. In simple episcleritis, vascular congestion is present in the absence of an obvious nodule.
The episclera is a fibroelastic structure consisting of two layers loosely joined together. The outer parietal layer, with the vessels of the superficial episcleral capillary plexus, is the more superficial layer. The superficial vessels appear straight and are arranged in a radial fashion. The deeper visceral layer contains a highly anastomotic network of vessels. Both of the vessel networks originate from the anterior ciliary arteries, which stem from the muscular branches of the ophthalmic artery. The episclera lies between the superficial scleral stroma and Tenon’s capsule. In contrast to simple episcleritis, nodular episcleritis has a less acute onset and more prolonged course.
Etiology
Most cases of episcleritis are idiopathic. Approximately 26-36% of patients have an associated systemic disorder. These include collagen-vascular diseases (rheumatoid arthritis, Crohn’s disease, ulcerative colitis, psoriatic arthritis, systemic lupus erythematosus, reactive arthritis (formerly Reiter’s syndrome), relapsing polychondritis, ankylosing spondylitis, and pustulotic arthro-osteitis), vasculitides (polyarteritis nodosa, temporal arteritis, Cogan’s syndrome, Churg-Strauss syndrome, granulomatosis with polyangiitis, Behcet’s disease), dermatologic disease (rosacea, pyoderma gangrenosum, Sweet’s syndrome), metabolic disease (gout), and atopy. The most common collagen vascular disease association is with rheumatoid arthritis. Malignancies, usually T-cell leukemia and Hodgkin’s lymphoma, can be associated with episcleritis. Foreign bodies and chemical injuries can also serve as inciting factors. Infectious agents do exist and include bacteria, mycobacteria, spirochetes (Treponema, Borrelia), Chlamydia, Actinomyces, fungi, herpes zoster & simplex, mumps, and chikungunya. Protozoa such as Acanthamoeba and Toxoplasmosis should be considered. Toxocara is another, albeit rare, cause. There has been at least one possible case of episcleritis as the initial presentation of COVID 19[1]. Lastly, medications such as topiramate and pamidronate can cause episcleritis.
Risk Factors
Most studies have shown that female adults are affected more commonly than male adults. However, one study of a pediatric population, revealed that boys were affected more commonly than girls. There are no specific risk factors; however, as mentioned above, a subset of patients will have an associated systemic disease. One study (Akpek et al)[2] found that 51% of patients have some concurrent eye disease.
General Pathology
In episcleritis, vascular congestion occurs in the superficial episcleral plexus. The episclera as well as Tenon’s capsule become infiltrated with inflammatory cells. The sclera is spared.
Pathophysiology
The exact mechanism for episcleritis remains a mystery.
Primary prevention
There is no primary prevention for episcleritis.
History
Classically, patients 20-50 years old will present with either acute (simple episcleritis) or gradual (nodular episcleritis) onset of redness in the eye, possibly associated with pain. In simple episcleritis, the episode usually peaks in about 12 hours and then slowly resolves over the next 2-3 days. It tends to recur in the same eye or both eyes at the same time; over time, the attacks become less frequent and, over years, disappear completely. The attacks may move between eyes. In nodular episcleritis, the redness is typically noted when the patient wakes up in the morning. Over the next few days, the redness enlarges, usually causing more discomfort, and takes on a nodular appearance. Episodes of nodular episcleritis are self-limited but tend to last longer than attacks of simple episcleritis.
Physical examination
The area of injection should be examined with the slit lamp. If the examiner uses a narrow, bright slit beam, nodular episcleritis can be distinguished from scleritis. In nodular scleritis, the inner reflection, which rests on the sclera and visceral layer, will remain undisturbed while the outer reflection will be displaced forward by the episcleral nodule. In scleritis, both of the light beams will be displaced forward. Also important to note is that the nodule in episcleritis is freely mobile over the scleral tissue that lies underneath.
Signs
Episcleritis is characterized by an area of diffuse or sectoral, bright red or pink bulbar injection. This is in contrast to the violaceous hue of scleritis. Eyelid edema and conjunctival chemosis may be present.
Symptoms
Patients with episcleritis will report the acute or gradual onset of diffuse or localized eye redness, usually unilateral. Some may not report any other symptoms, while others may report discomfort, photophobia, or tenderness. Complaints of severe pain or ocular discharge should prompt reconsideration of the diagnosis of episcleritis.
Clinical diagnosis
Episcleritis is a clinical diagnosis, based primarily on history as well as external and slit lamp examination.
Diagnostic procedures
In practice, the differentiation of episcleritis and scleritis is often aided by the instillation of phenylephrine 2.5%. The phenylephrine blanches the conjunctival and episcleral vessels but leaves the scleral vessels undisturbed. If a patient's eye redness improves after phenylephrine instillation, the diagnosis of episcleritis can be made. According to Krachmer et al[3], phenylephrine 2.5% eye drops blanch conjunctival vessels, allowing the differentiation of conjunctivitis and episcleritis. Instillation of phenylephrine 10% will result in blanching of the superficial episcleral vascular network but not the deep plexus, thus distinguishing between episcleritis and scleritis.
Laboratory test
Single episodes of episcleritis do not require an extensive laboratory workup; however, patients who experience recurrent attacks and do not have any known associated diseases may require systemic evaluation. The basic tests to order include rheumatoid factor, antinuclear antibody, serum uric acid, erythrocyte sedimentation rate (ESR), complete blood count with differential, VDRL/FTA-ABS, urinalysis, PPD, and a chest x-ray. The choice of tests to be done in specific patients should be tailored for each individual based on the history, review of systems, and examination.
Differential diagnosis
The differential diagnosis for cases of episcleritis includes conjunctivitis, phlyctenular conjunctivitis, scleritis, and, rarely, episcleral plasmacytoma. For nodular episcleritis, local causes such as a foreign body or granuloma should be ruled out as the causes for the episcleral nodule. The differential diagnosis might also include pingueculitis.
Management is generally supportive alone.
General treatment
Episcleritis typically clears on its own without treatment and reassurance is the primary step in management. Some patients, however, may experience significant pain or discomfort or may dislike the appearance of the condition. In such cases, supportive measures, such as cool compresses and iced artificial tears, or medical therapy (see below) can be initiated.
Medical therapy
Oral NSAIDs (nonsteroidal anti-inflammatory drugs), typically 800 mg ibuprofen three times daily, are the mainstay of treatment for episcleritis. Alternative medications include indomethacin 25mg to 75 mg twice daily or flurbiprofen 100 mg three times daily. Studies comparing topical flurbiprofen and ketorolac to placebo found no difference in effectiveness in resolving the injection. The use of weak topical steroids (administered 1-4 times daily until symptoms resolve) is often employed[4][5]; however, some find their use controversial. Although they bring about a timely control of the condition, steroids may increase the risk of recurrence and cause ‘rebound’ redness followed by a more intense attack. In patients with collagen vascular disease, measures targeted at the underlying disease itself can achieve control of the episcleritis.
Episcleritis sometimes occurs in the setting of dry eye syndrome and blepharitis and attention to these two underlying issues is likely to be of benefit.
Medical follow-up
Regular follow-up is not required unless a patient does not notice any improvement in his or her symptoms. Most isolated episodes of episcleritis resolve completely over 2-3 weeks. Those cases that are associated with systemic disease can take on a more prolonged course with multiple recurrences. Patients who are prescribed topical steroids should be monitored.
Surgery
There are no surgical therapies for episcleritis.
Complications
Episcleritis is largely benign; however, there have been reports of a few complications in patients with recurrent disease. These include anterior and intermediate uveitis, as well as corneal dellen (adjacent to an episcleral nodule) and peripheral corneal infiltrates (adjacent to episcleral inflammation). Declining vision, in the setting of episcleritis, is typically attributed to advancing cataracts. Glaucoma has also been noted in a minority of patients. Both cataracts and glaucoma could be related to steroid use as part of the management of episcleritis.
Prognosis
Episcleritis is a benign, self-limited condition that usually resolves completely over the course of a few weeks.
General references:
- Kanski, Jack J. Clinical Ophthalmology: A Systematic Approach. China: Elsevier Inc, 201#
- External Disease and Cornea, Section # Basic and Clinical Science Course, AAO, 2010.
- Honik G, Wong IG, Gritz DC; Incidence and prevalence of episcleritis and scleritis in Northern California. Cornea. 2013 Dec;32(12):1562
Specific references:
- ↑ Otaif, Al Somali, Al Habash, " Episcleritis as a possible presenting sign of the novel coronavirus disease: a case report. AJO Case Reports, Vol 20, Dec 2020
- ↑ Akpek EK, Uy H, Christen W, et al. Severity of episcleritis and systemic disease association. Ophthalmology. 1999;106:729.
- ↑ Krachmer J, Mannis MJ, Holland EJ. Cornea. China: Elsevier, Inc, 201#
- ↑ Berchicci L, Miserocchi E, Di Nicola M, La Spina C, Bandello F, Modorati G. Clinical features of patients with episcleritis and scleritis in an Italian tertiary care referral center. Eur J Ophthalmol. 2014 May-Jun. 24 (3):293-8.
- ↑ Jabs DA, Mudun A, Dunn JP, Marsh MJ. Episcleritis and scleritis: clinical features and treatment results. Am J Ophthalmol. 2000 Oct;130(4):469-76. doi: 10.1016/s0002-9394(00)00710-8. PMID: 11024419.
FAQs
How do you treat episcleritis? ›
Episcleritis generally clears without treatment, but topical or oral anti-inflammatory agents maybe prescribed to relieve pain or in chronic/recurrent cases. It is treated at Wilmer by the Ocular Surface Diseases and Dry Eye Clinic.
How can you tell the difference between scleritis and episcleritis? ›Scleritis is characterized by significant pain, pain with eye movement, vision loss, and vessels that do not blanch with phenylephrine. Episcleritis is typically less painful with no vision loss. Vessels blanch with phenylephrine drops and can be moved by a cotton swab.
What is an episcleritis? ›Episcleritis is a relatively common, benign, self-limited cause of red eye, due to inflammation of the episcleral tissues. There are two forms of this condition: nodular and simple. Nodular episcleritis is characterized by a discrete, elevated area of inflamed episcleral tissue.
How is episcleritis diagnosed? ›To diagnose episcleritis, your eye doctor will give you a thorough eye exam. They'll likely start by looking at the color of your eyes. If the discoloration is more of a bluish purple, rather than red, they might diagnose you with scleritis instead. You'll also be given a slip lamp exam.
What causes episcleritis to flare up? ›It sometimes flares up when you are tired, have been reading or working for long periods on computers, or are in a dry, dusty environment. Very rarely, it may be due to an underlying inflammation in your body; this can be investigated by blood tests if the episcleritis is severe and recurrent.
How can I get rid of episcleritis naturally? ›Most cases of episcleritis go away on their own within 7 and 10 days. For more severe cases, an eye doctor may prescribe oral anti-inflammatory medication, a topical anti-inflammatory ointment or eye drops. A cold compress may be used at home to provide relief from episcleritis symptoms.
Is episcleritis caused by stress? ›Episclera is a highly vascular tissue that lies above the sclera and beneath the conjunctiva. Episcleritis is an inflammatory response likely caused by oxidative stress, which causes tissue inflammation.
Is episcleritis worse at night? ›Presents early, as symptoms are severe. Boring eye pain, often radiating to the forehead, brow and jaw and usually severe. Worst in necrotising scleritis; may be mild or absent in scleromalacia perforans. Pain worse with movement of the eye and at night (may wake the patient).
Is episcleritis autoimmune? ›Description. Episcleritis is an inflammation of the white tissue, the sclera, that surrounds most of the eye. Though scleritis is a symptom of a number of autoimmune diseases, it is suspected of being an autoimmune disease itself.
Should I go to the doctor for episcleritis? ›When to Contact a Medical Professional. Call your health care provider if you have symptoms of episcleritis that last for more than 2 weeks. Get checked again if your pain gets worse or you have problems with your vision.
How long does it take for episcleritis to resolve? ›
Most attacks resolve within 1–3 months. The nodular type tends to be more recurrent and painful. It presents with acute onset of redness, lacrimation, and photophobia.
How can episcleritis be prevented? ›You cannot prevent getting a case of episcleritis. The best way to avoid the eye condition is to address its underlying cause, which is usually a systemic inflammatory disease such as rheumatoid arthritis.
Is episcleritis chronic? ›C. Episcleritis usually is a benign recurring condition. Episcleritis usually resolves without treatment in 2 to 21 days. Episcleritis does not progress to scleritis except in herpes zoster, which sometimes starts as an episcleritis and shows the vesicular stage of the eruption.
Can episcleritis spread? ›Scleritis is much less common and more serious. It tends to come on more slowly and affects the deep white layer (sclera) of the eye. It can spread to affect the adjacent layers around the sclera, including the episclera and the cornea.
Can episcleritis turn into uveitis? ›Although often self-limited, episcleritis can be associated with corneal involvement, uveitis, and glaucoma. Extensive evaluation for underlying disease may not be warranted for mild forms of the disease, especially if it is not recurrent.
Is episcleritis caused by allergies? ›Episclera is a thin layer of tissue present between the conjunctiva and sclera. There are mainly four causes of episcleritis: an allergic response, autoimmune, vascular disease, or infections. The symptoms are redness, erythema, discomfort in the eyes, and clear discharge.
Can episcleritis cause vision loss? ›In some cases of episcleritis, scleritis may develop, an inflammation of the sclera that can cause intense pain and loss of vision. Contact your healthcare provider if you have symptoms of episcleritis that last for more than 2 weeks or if you have a loss of vision.
Can episcleritis cause dry eyes? ›Episcleritis patients were 3.3 times (CI 1.73 to 6.34) more likely to have a concurrent diagnosis of dry eye syndrome compared to non-episcleritis patients. Conclusions: Episcleritis is more common in females and in association with dry eye syndrome. Treatment of dry eye syndrome may be beneficial in episcleritis.
What autoimmune disease causes scleritis? ›Causes. Scleritis is often linked to autoimmune diseases. These diseases occur when the body's immune system attacks and destroys healthy body tissue by mistake. Rheumatoid arthritis and systemic lupus erythematosus are examples of autoimmune diseases.
Can eye inflammation heal on its own? ›Anterior: The most common type, anterior uveitis causes inflammation in the front of the eye. Symptoms may appear suddenly and can occasionally resolve on their own if they are mild. Some people have chronic, recurring eye inflammation that goes away with treatment and then comes back.
Can episcleritis cause headaches? ›
Episcleritis / scleritis: Episcleritis would usually present with sectoral or nodular redness with associated headaches or eye ache. It is important to differentiate that from scleritis. Usually the pain in scleritis is more intense and tends to happen at night.
How do I get rid of inflammation in my eye naturally? ›Aloe vera. Because of aloe vera's anti-inflammatory and antibacterial properties, some natural healers recommend using it to alleviate sore eyes. Mix 1 teaspoon of fresh aloe vera gel into 2 tablespoons of cold water, and then soak cotton rounds in the mixture.
What does episcleritis look like? ›When the tiny blood vessels in the episclera get irritated or inflamed, they make your eye look red or bloodshot. It usually happens in just one eye but can affect both. Though the redness may look like conjunctivitis, or pinkeye, there's no goopy discharge.
Is episcleritis itchy? ›The symptoms of episcleritis include: Red, inflamed-looking whites of the eye - either just one area or the whole white. Mild pain, tenderness, burning or itching.
Why is one of my eyes red when I wake up? ›Causes of red eyes in the morning. The sclera, or whites of your eyes, are filled with tiny blood vessels. If these blood vessels become dilated or swollen, red eyes will result, especially upon waking. Red eyes upon waking can often be alleviated by changing lifestyle habits.
Why is half of my eye red? ›A subconjunctival hemorrhage can result from a minor injury or trauma to the eye, including rubbing the eye due to allergies. Common causes also include coughing, sneezing, and straining. People who have diabetes, have high blood pressure, or take certain medications, such as blood thinners, may have a higher risk.
Can an optometrist diagnose scleritis? ›One in 10 cases of Scleritis takes the form known as Posterior Scleritis, which affects the sclera of the back part of the eye, so that the front of the eye may appear normal and the optometrist will need to use special instruments to help to make the diagnosis.
Who treats episcleritis? ›It can occur in both eyes simultaneously, but more often occurs just in one, and almost never causes any permanent damage. Most often it is seen and treated by general ophthalmologists or even primary care physicians, unless the problem becomes more frequent or severe.
What are the 11 signs of lupus? ›- A butterfly-shaped rash across both sides of the face.
- Raised, red skin patches.
- Sensitivity to light.
- Ulcers in the mouth or nose.
- Arthritis plus swelling or tenderness in two or more joints.
- Seizures or other nervous system problems.
- Excessive protein in urine.
...
| Episcleritis | |
|---|---|
| Prognosis | Good |
How long does inflammation in the eye last? ›
Outlook for Iritis
Iritis that's caused by an injury usually goes away within 1 or 2 weeks. Other cases may take weeks or months to clear up. If a bacteria or virus causes your iritis, it will go away after you treat the infection.
There isn't always an obvious reason it happens, but most of the time, it's caused by an autoimmune disorder (when your body's defense system attacks its own tissues). Some of those that are linked to scleritis include: Rheumatoid arthritis. Lupus.
What causes inflamed blood vessels in eye? ›Retinal vasculitis is a sight-threatening inflammatory eye condition that involves the retinal vessels. It may occur as an isolated idiopathic condition, as a complication of infective or neoplastic disorders, or in association with systemic inflammatory disease1 [Table 1].
Why is scleritis worse at night? ›The symptoms of pain and/or headache are reported frequently by patients with scleritis and are often worse at night due to dependent or positional tissue swelling.
Can Lyme cause episcleritis? ›Lyme disease is the most common arthropod-related infectious disease caused by a spirochete known as Borrelia burgdorferi. Ocular involvement of Lyme disease is characterized by conjunctivitis, episcleritis, keratitis, uveitis, neuroretinitis, retinal vasculitis and cranial nerve palsies.
Can I wear contact lenses with episcleritis? ›Contact lens wear should be halted until the condition resolves. In moderate-to-severe cases, especially in nodular episcleritis, therapeutic intervention is necessary.
How do you get rid of a red eye fast? ›- Use over-the-counter artificial tears. ...
- Use over-the-counter antihistamine eye drops, especially if you are prone to seasonal allergies. ...
- Use decongestants. ...
- Place cool compresses or washcloths on your closed eyes a couple of times a day.
Nodular episcleritis is more indolent and may require local corticosteroid drops or anti-inflammatory agents. Topical ophthalmic 0.5% prednisolone, 0.1% dexamethasone, loteprednol etabonate 0.5%, or 0.1% betamethasone daily may be used.
How long does it take for episcleritis to heal? ›Usually, simple episcleritis will clear up on its own in a week to 10 days. An eye doctor can give or prescribe lubricating eye drops to soothe the irritation and redness. They also may prescribe a nonsteroidal anti-inflammatory drug (or NSAID), such as ibuprofen.
What happens if episcleritis doesn't go away? ›If episcleritis does not settle over a week or if the pain becomes worse and your vision is affected, you should see a doctor in case you have scleritis.
Is episcleritis caused by stress? ›
Episclera is a highly vascular tissue that lies above the sclera and beneath the conjunctiva. Episcleritis is an inflammatory response likely caused by oxidative stress, which causes tissue inflammation.
What autoimmune disease can cause episcleritis? ›These conditions include but are not limited to rheumatoid arthritis, Crohn disease, ulcerative colitis, psoriatic arthritis, systemic lupus erythematosus, reactive arthritis, relapsing polychondritis, ankylosing spondylitis, polyarteritis nodosa, Behcet disease, Cogan syndrome, and granulomatosis with polyangiitis, ...
Is episcleritis worse at night? ›Presents early, as symptoms are severe. Boring eye pain, often radiating to the forehead, brow and jaw and usually severe. Worst in necrotising scleritis; may be mild or absent in scleromalacia perforans. Pain worse with movement of the eye and at night (may wake the patient).
Is episcleritis chronic? ›C. Episcleritis usually is a benign recurring condition. Episcleritis usually resolves without treatment in 2 to 21 days. Episcleritis does not progress to scleritis except in herpes zoster, which sometimes starts as an episcleritis and shows the vesicular stage of the eruption.
How can episcleritis be prevented? ›You cannot prevent getting a case of episcleritis. The best way to avoid the eye condition is to address its underlying cause, which is usually a systemic inflammatory disease such as rheumatoid arthritis.
Who treats episcleritis? ›It can occur in both eyes simultaneously, but more often occurs just in one, and almost never causes any permanent damage. Most often it is seen and treated by general ophthalmologists or even primary care physicians, unless the problem becomes more frequent or severe.
Is episcleritis common? ›Episcleritis is the inflammation of the thin, loose, highly vascular connective tissue layer that lies between the conjunctiva and sclera. Incidence is less than 1/1000. It is more common in women and those between 40 and 50 years of age. Most cases are idiopathic.
Can episcleritis turn into uveitis? ›Although often self-limited, episcleritis can be associated with corneal involvement, uveitis, and glaucoma. Extensive evaluation for underlying disease may not be warranted for mild forms of the disease, especially if it is not recurrent.
Is episcleritis caused by allergies? ›Episclera is a thin layer of tissue present between the conjunctiva and sclera. There are mainly four causes of episcleritis: an allergic response, autoimmune, vascular disease, or infections. The symptoms are redness, erythema, discomfort in the eyes, and clear discharge.
How do I get rid of inflammation in my eye naturally? ›Aloe vera. Because of aloe vera's anti-inflammatory and antibacterial properties, some natural healers recommend using it to alleviate sore eyes. Mix 1 teaspoon of fresh aloe vera gel into 2 tablespoons of cold water, and then soak cotton rounds in the mixture.
Can eye inflammation heal on its own? ›
Anterior: The most common type, anterior uveitis causes inflammation in the front of the eye. Symptoms may appear suddenly and can occasionally resolve on their own if they are mild. Some people have chronic, recurring eye inflammation that goes away with treatment and then comes back.
What are the 11 signs of lupus? ›- A butterfly-shaped rash across both sides of the face.
- Raised, red skin patches.
- Sensitivity to light.
- Ulcers in the mouth or nose.
- Arthritis plus swelling or tenderness in two or more joints.
- Seizures or other nervous system problems.
- Excessive protein in urine.
Description. Collapse Section. Neuromyelitis optica is an autoimmune disorder that affects the nerves of the eyes and the central nervous system, which includes the brain and spinal cord. Autoimmune disorders occur when the immune system malfunctions and attacks the body's own tissues and organs.
Can episcleritis cause headaches? ›Episcleritis / scleritis: Episcleritis would usually present with sectoral or nodular redness with associated headaches or eye ache. It is important to differentiate that from scleritis. Usually the pain in scleritis is more intense and tends to happen at night.