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Symptoms ⬇

Acute or rapid onset of redness and mild pain in one or both eyes, typically in young-to middle-aged adults, more common in women; a history of recurrent episodes is common. No discharge or photophobia.

Signs ⬆ ⬇

Critical

Sectoral (and, less commonly, diffuse) redness of one or both eyes, mostly due to engorgement of the episcleral vessels. These vessels are large, run in a radial direction beneath the conjunctiva, and can be moved slightly with a cotton-tip applicator (see Figure 5.6.1).

5-6.1 Episcleritis.

Gervasio-ch005-image013

Other

Mild-to-moderate tenderness over the area of episcleral injection or a nodule that can be moved slightly over the underlying sclera may be seen. Fluorescein staining can sometimes be seen over the nodule. Associated anterior uveitis and corneal involvement are rare. Vision is normal.

Differential Diagnosis ⬆ ⬇

  • Scleritis: Typically older patient. May have known underlying immune-mediated disease (e.g., collagen vascular disease). Pain is deep, severe, and often radiates to the ipsilateral side of the head or face. The sclera may have a violaceous hue when observed in natural light. Scleral (and deep episcleral) vessels, as well as conjunctival and superficial episcleral vessels, are injected. The scleral vessels do not blanch on application of topical phenylephrine 2.5%. Possible corneal involvement with adjacent peripheral stromal keratitis. See 5.7, SCLERITIS.
  • Iritis: Cells and flare in the anterior chamber. May be present with scleritis. See 3.5, TRAUMATIC IRITIS and 12.1, ANTERIOR UVEITIS (IRITIS/IRIDOCYCLITIS).
  • Conjunctivitis: Diffuse redness and discharge with follicles or papillae. See 5.1, ACUTE CONJUNCTIVITIS and 5.2, CHRONIC CONJUNCTIVITIS.
  • Contact lens-related: Overwear, tight contact lens syndrome, or reaction to contact lens solution. Must be considered in all contact lens wearers. See 4.20, CONTACT LENS-RELATED PROBLEMS.

Etiology ⬆ ⬇

  • Idiopathic: Most common; 60% of patients have no underlying systemic disease.
  • Infectious: Herpes zoster virus (scars from an old facial rash may be present, may cause episcleritis or scleritis), sexually transmitted infections, protozoa, and others.
  • Medications (e.g., topiramate and pamidronate).
  • Others: Rosacea, atopy, collagen vascular diseases (e.g., rheumatoid arthritis, inflammatory bowel disease, ankylosing spondylitis, psoriatic arthritis, systemic lupus erythematosus), vasculitides, and gout.

Work Up ⬆ ⬇

Workup
  1. History: Assess for a history of rash, arthritis, venereal disease, recent viral illness, and other medical problems.
  2. External examination in natural light: Look for the violaceous hue of scleritis.
  3. Slit lamp examination: Anesthetize (e.g., topical proparacaine) and move the conjunctiva with a cotton-tipped applicator to determine the depth of the injected blood vessels. Evaluate for any corneal or anterior chamber involvement. Check IOP.
  4. Place a drop of phenylephrine 2.5% in the affected eye and re-examine the vascular pattern 10 to 15 minutes later. Episcleral vessels should blanch, highlighting any underlying scleral vascular engorgement.
  5. If the history suggests an underlying etiology (systemic disease usually precedes ocular involvement), or in cases with multiple recurrences, the appropriate laboratory tests should be obtained (e.g., complete blood count, comprehensive metabolic panel, antinuclear antibody [ANA], rheumatoid factor, anticyclic citrullinated peptide [anti-CCP], erythrocyte sedimentation rate [ESR], serum uric acid level, RPR or VDRL, FTA-ABS or treponemal-specific assay, antineutrophil cytoplasmic antibody [ANCA]).

Treatment ⬆ ⬇

  1. If mild, treat with artificial tears q.i.d.
  2. If moderate to severe, a topical NSAID (e.g., diclofenac 0.1% q.i.d., bromfenac 0.07% or 0.09% daily) or a mild topical steroid (e.g., fluorometholone 0.1% or 0.25%, fluorometholone acetate 0.1% or loteprednol 0.5% q.i.d.) often relieves the discomfort. Occasionally, more potent or frequent topical steroid application is necessary.
  3. Oral NSAIDs may be used as an alternate steroid-sparing initial therapy and should be given with food or antacids (e.g., ibuprofen 200 to 600 mg p.o. t.i.d. to q.i.d., naproxen 250 to 500 mg p.o. b.i.d., or flurbiprofen 50 to 100 mg p.o. b.i.d. to t.i.d.) for at least 10 to 14 days.
NOTE:

Many physicians prefer oral NSAIDs to topical NSAIDs or steroids as initial therapy.

Follow Up ⬆

Patients treated with artificial tears need not be seen for several weeks unless discomfort worsens or persists. If topical steroids are used, recheck every 2 to 3 weeks until symptoms resolve. The frequency of steroid administration is then tapered. Episcleritis may recur in the same or contralateral eye.