Episcleritis

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

Idiopathic inflammation of the vascular connective tissue layer that lies between the sclera and conjunctiva

Predisposing factors

  • Up to one third of cases (especially nodular variety) associated with systemic disorders, e.g.
    • collagen vascular diseases
      • rheumatoid arthritis
      • systemic lupus erythematosus
      • inflammatory bowel disease
  • Also other conditions including gout, ocular rosacea (NB importance of careful history taking)
  • Previous history of episcleritis
  • Herpes Zoster Ophthalmicus
  • Commonest in 4th or 5th decades

Symptoms

  • Acute onset
  • Typically unilateral red eye, but bilateral in a quarter to a half of cases
  • Mild ache or burning sensation
  • Sometimes tender on palpation
  • Occasionally watery
  • Condition commonly recurrent

Signs

  • Hyperaemia from dilated episcleral vessels
    (NB these follow a regular radiating pattern and are immovable, unlike the finer overlying conjunctival vessels which move freely with the conjunctiva).
  • Hyperaemia blanches with vasoconstrictors (e.g. gutt. phenylephrine 10%)
  • Simple (80%)
    • sectoral or diffuse redness
  • Nodular (20%)
    • nodule (mild elevation of the conjunctiva) with injection
  • Typically no anterior chamber reaction
  • Usually no corneal or palpebral conjunctival involvement
  • No effect on visual acuity

Differential diagnosis

  • Scleritis (see Clinical Management Guideline on Scleritis)
  • Conjunctivitis (viral, bacterial, allergic)
  • Phlyctenular keratoconjunctivitis
  • Anterior uveitis

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological
  • Usually self-limiting in 7-10 days
  • Reassurance: condition does not generally progress to more serious ocular disorder
  • Cold compresses
  • Advise patient to return/seek further help if symptoms persist

(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

Pharmacological

(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

  • Inconsistent evidence for benefit of topical NSAIDs (off-licence use)

(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)
 

  • More severe cases (including nodular type) may need mild topical steroid e.g. fluorometholone for 1-2 weeks

(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)
 

  • Severe cases may benefit from systemic non-steroidal anti-inflammatory treatment, e.g. flurbiprofen 100mg tds or naproxen 500mg bd

(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)

NB patients on topical steroids should be re-examined after 7-10 days (including IOP measurement) (see Clinical Management Guideline on Glaucoma [steroid])

Management category

B3: management to resolution
B1: at second recurrence (third episode), refer for investigation

Possible management by ophthalmologist

Investigation for underlying systemic disease

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation  (www.gradingworkinggroup.org)
 

Sources of evidence

Lloyd-Jones D, Tokarewicz A, Watson PG. Clinical evaluation of clobetasone butyrate eye drops in episcleritis. Br J Ophthalmol. 1981;65(9):641-3

Lyons CJ, Hakin KN, Watson PG. Topical flurbiprofen: an effective treatment for episcleritis? Eye (Lond). 1990;4(3):521-5

Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA, Doctor PP, Tauber J, Foster CS. Clinical characteristics of a large cohort of patients with scleritis and episcleritis. Ophthalmology. 2012;119(1):43-50

Watson PG, Lobascher DJ, Sabiston DW, Lewis-Faning E, Fowler PD, Jones BR. Double-blind trial of the treatment of episcleritis-scleritis with oxyphenbutazone or prednisolone. Br J Ophthalmol. 1966;50(8):463-81

Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol 1976;60:163-91

Williams CP, Browning AC, Sleep TJ, Webber SK, McGill JI. A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis. Eye (Lond). 2005;19(7):739-42

Lay summary

Episcleritis is an inflammation of the episclera, the tissue that lies just under the outer skin of the white of the eye. Commonest between the ages of 40 to 60, it usually affects just one eye but both eyes are affected in a quarter to a half of cases. In about one in three of cases there is a background of inflammation elsewhere in the body, for example rheumatoid arthritis or inflammation of the bowel.

The condition begins without warning and patients experience redness, aching and tenderness of one or both eyes. The vision is not affected. Episcleritis may disappear in a week to ten days and return again later. The optometrist will reach a diagnosis based on the exact type of inflammation, which distinguishes this condition from conjunctivitis (inflammation of the outer skin of the eye) and scleritis (inflammation of the white part of the eyeball).
Cold compresses may relieve the symptoms, as may artificial tears in eye drop form. If the inflammation is more severe, steroid eye drops may be prescribed, and sometimes antiinflammatory tablets are needed also.

After the second recurrence, the optometrist will normally refer the patient for investigation by the ophthalmologist.

Episcleritis
Version 9
Date of search 21.06.15
Date of revision 18.09.15
Date of publication 20.10.15
Date for review 20.06.17
© College of Optometrists 

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