What is episcleritis?
Episcleritis is inflammation of the episclera, the thin, vascular, superficial layer that covers the sclera. The sclera itself is the white outer layer of the eye. Episclera lies underneath the conjunctiva and other connective tissues. Unlike the more severe condition, scleritis, episcleritis is typically benign and is only occasionally associated with systemic inflammatory diseases. The inflamed vessels in episcleritis are located within the episclera, whereas in scleritis the inflammation involves the deeper scleral vascular plexus. Clinically, the redness may be sectoral or diffuse, and in some cases may present as a localized inflammatory nodule.
It can occur in both eyes simultaneously, but more often affects only one eye and rarely causes permanent damage. It is most commonly evaluated and managed by general ophthalmologists or even primary care physicians, unless it becomes more frequent or severe.
What are the symptoms of episcleritis?
Redness is the primary symptom of episcleritis. Patients may also report mild discomfort, irritation, or a burning sensation. Symptoms can begin and resolve abruptly even without treatment and may recur. Significant pain is typically absent, and the eye is usually not tender to touch or markedly sensitive to light. The presence of these features suggests scleritis as an alternative diagnosis.
Do I have episcleritis or scleritis?
This is the most common point of confusion for patients with inflammation of the ocular surface and, unfortunately, also for many optometrists and general ophthalmologists who evaluate these patients at initial presentation. Redness is common to both conditions, but in episcleritis it involves the more superficial vessels of the episclera, whereas in scleritis it involves the deeper scleral vascular plexus. In episcleritis, this redness will largely disappear when your ophthalmologist instills phenylephrine 2.5% (and sometimes 10%); however, in scleritis, the deeper vessels will remain red and inflamed despite the use of these drops. Episcleritis is typically painless, or at best annoying. Pain and tenderness, however, are hallmarks of scleritis, especially pain that worsens with eye movement or radiates to different parts of the head, mimicking headache, sinus disease, or tooth ache. Bottom line: if the eye is significantly painful and red, it is likely something other than episcleritis.
What causes episcleritis?
Unfortunately, the exact cause is largely unknown. It is thought to involve inflammation of the soft tissue and small vessels along the eye wall, a process consistent with microangiopathy and similar, though less severe, to that seen in scleritis. The degree of inflammation and the underlying immunologic mechanisms in episcleritis are much less pronounced than in scleritis.
What other medical conditions are associated with episcleritis?
Episcleritis is usually not associated with any systemic disease. Only about 3 out of 10 people with episcleritis have an associated systemic disease. It can, however, present in a wide variety of conditions causing ocular surface inflammation, including collagen-vascular diseases (such as lupus or rheumatoid arthritis), infections, rosacea, gout, or even allergy. A work-up is not always done for episcleritis unless it is frequent, stubborn, or severe.
What are complications from episcleritis?
Episcleritis does not cause permanent damage to the eye. Rarely, it can be accompanied by mild inflammation of the peripheral cornea or inflammatory cells inside the eye. There are times, however, when a patient may later develop scleritis after first having episcleritis, and at that point vision threatening complications become a concern. Sadly, complications from episcleritis sometimes occur from treatment of episcleritis because of long term use of corticosteroid eye drops.
How do you treat episcleritis?
Treatment of episcleritis is most often conservative. Observation without treatment may be all that is necessary for episcleritis that does not cause significant redness or irritation. Lubricating drops can help both soothe irritation as well as reduce surface inflammation. More often a topical non-steroidal anti-inflammatory drug (NSAID) is used on a daily basis, either until symptoms are resolved, or can be used safely long-term in cases of recurrent episcleritis. Corticosteroid eye drops may help to relieve episcleritis but should never be relied on as a long-term treatment due to inevitable complications of cataract and glaucoma. If episcleritis is particularly persistent or severe, oral NSAID therapy may be used. However, in such cases, a more comprehensive evaluation for underlying inflammatory disease should be considered. Redness, irritation, or pain requiring more aggressive treatment should prompt reevaluation by a specialist to assess for a more serious condition, such as scleritis.
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