Episcleritis

Background

• Abrupt onset of inflammation in the episclera
• 70% of cases occurs in women (usually young/middle-aged)
• Usually a benign, self-limited condition
• Can be classified into simple (more common) or nodular types
• Most commonly idiopathic but may occur as an ocular manifestation of underlying autoimmune conditions eg RA, IBD

Clinical Features

Episcleritis

History

• Abrupt onset of redness, irritation, and watering of the eye
• Pain is unusual
• Vision unaffected
• 50% of cases are bilateral

Physical exam

• Vasodilatation of the superficial episcleral vessels
• Focal area(s) of redness
• May have a tender scleral nodule (nodular episcleritis)

Differential Diagnosis

Unilateral red eye

• Nontraumatic
  • Acute angle-closure glaucoma^
  • Anterior uveitis
  • Conjunctivitis
  • Corneal erosion
  • Corneal ulcer^
  • Endophthalmitis^
  • Episcleritis
  • Herpes zoster ophthalmicus
  • Inflamed pinguecula
  • Inflamed pterygium
  • Keratoconjunctivitis
  • Keratoconus
  • Nontraumatic iritis
  • Scleritis^
  • Subconjunctival hemorrhage
• Orbital trauma
  • Caustic keratoconjunctivitis^^
  • Corneal abrasion, Corneal laceration
  • Conjunctival hemorrhage
  • Conjunctival laceration
  • Globe rupture^
  • Hemorrhagic chemosis
  • Lens dislocation
  • Ocular foreign body
  • Posterior vitreous detachment
  • Retinal detachment
  • Retrobulbar hemorrhage
    • Ocular compartment syndrome
  • Traumatic hyphema
  • Traumatic iritis
  • Traumatic mydriasis
  • Traumatic optic neuropathy
  • Vitreous detachment
  • Vitreous hemorrhage
  • Ultraviolet keratitis

^Emergent diagnoses ^^Critical diagnoses

Evaluation

• Must distinguish from scleritis
  • Scleritis likely to have pain and decreased vision
  • Use of 2.5% phenylephrine drops will cause vasoconstriction/blanching of episcleral but not scleral vessels. Thus, there will be decreased injection and redness in episcleritis but not scleritis.
  • Red area will be mobile if moved with a moist q-tip
• Must distinguish from conjunctivitis
  • Episcleritis will usually have a sectoral pattern of injection, as opposed to a diffuse injection seen in conjunctivitis.

Management

• Topical lubricants
  • Artificial tears q4-6hr
• Oral NSAIDs

Disposition

• Refer to ophtho is unsure of diagnosis or if steroids are necessary for Tx
• Self-limiting (will resolve within 2-3 weeks)

See Also

• Scleritis