EPISCLERITIS

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for
Medical Sciences

Background
Episcleritis is an inflammatory condition affecting the episcleral tissue that lies between
the conjunctiva and the sclera.[1, 2] Episcleritis is usually a mild, self-limiting, recurrent disease.
Most cases are idiopathic, although up to one third have an underlying systemic condition. Some
cases may be caused by exogenous inflammatory stimuli.[3, 4, 5]

Epidemiology
Frequency
United States
True frequency is difficult to determine since many patients do not seek medical attention.
Sex
Some authors report no difference, while other authors report that up to 74% of cases occur in
females.
Age
Episcleritis is most common in the fourth to fifth decades.

Pathophysiology
The pathophysiology is poorly understood. The inflammatory response is localized to the
superficial episcleral vascular network, and histopathology shows nongranulomatous
inflammation with vascular dilatation and perivascular infiltration.
The 2 clinical types are simple and nodular. The most common type is simple episcleritis,
in which there are intermittent bouts of moderate-to-severe inflammation that often recur at 1- to
3-month intervals. The episodes usually last 7-10 days, and most resolve after 2-3 weeks.
Prolonged episodes may be more common in patients with associated systemic conditions. Some
patients note that episodes are more common in the spring or fall. The precipitating factor is
rarely found, but attacks have been associated with stress, allergy, trauma, and hormonal
changes.

Patients with nodular episcleritis have prolonged attacks of inflammation that are
typically more painful than simple episcleritis. Many patients with nodular episcleritis have an
associated systemic disease.[6]

History
All patients should undergo a thorough history, including a review of systems. Many
patients complain of acute onset of mild-to-moderate discomfort, although some may notice an
area of painless injection. Photophobia and watery discharge may be noted.

Physical
A diffuse or localized injection of the bulbar conjunctiva is often present. A watery
discharge is observed in some patients. A freely moveable nodule may be present in nodular
episcleritis. Corneal findings are uncommon and include dellen formation as well as peripheral
corneal infiltrates. An associated anterior uveitis may occur in as many as 10% of patients.

Causes
Most cases are idiopathic; however, up to one third of cases may have an underlying
systemic condition.[7, 8, 9]
Collagen-vascular diseases are as follows:

Rheumatoid arthritis
Systemic lupus erythematosus
Polyarteritis nodosa
Seronegative spondyloarthropathies
- Ankylosing
spondylitis, inflammatory
bowel disease, reactive arthritis, psoriatic
arthritis

Bacteria,
including tuberculosis, Lyme
disease,
and syphilis
Viruses, including herpes simplex
and herpes zoster
Fungi
Parasites
Other rare
follows:

causes/associations

are

as

Miscellaneous causes are as follows:

Gout
Atopy
Foreign bodies
Chemicals
Infectious disease causes are as follows:

T-cell leukemia
Paraproteinemia
Paraneoplastic syndromes - Sweet
syndrome, dermatomyositis
Wiskott-Aldrich syndrome
Adrenal cortical insufficiency
Necrobiotic xanthogranuloma
Progressive hemifacial atrophy

Following transscleral fixation of

posterior chamber intraocular lens

Insect bite granuloma

Malpositioned Jones tube

Differential Diagnoses

Scleritis in Emergency Medicine

Superior Limbic Keratoconjunctivitis

Viral Conjunctivitis

Laboratory Studies
All patients should undergo a thorough history, including a review of systems. Results of
this review and findings from the physical examination are used to determine the need for
specific laboratory studies. In most patients with mild self-limited disease, laboratory studies are
not useful.
Some patients with an unremarkable review of systems may benefit from a limited
workup. This includes patients with nodular episcleritis or those with severe and
recurrent/persistent simple episcleritis. Useful laboratory studies in this group of patients include
serum uric acid, complete blood count with differential, antinuclear antibody, rheumatoid factor,
erythrocyte sedimentation rate, Venereal Disease Research Laboratory (VDRL) test, fluorescent
treponemal antibody absorption (FTA-ABS) test, and chest x-ray.

Histologic Findings
Histologic findings include nongranulomatous inflammation with perivascular infiltrates
and vascular dilatation.

Imaging Studies
Evaluations of the sclera and episclera using anterior segment optical coherence
tomography (OCT) may help monitor the effectiveness of therapy.[10]

Medical Care
Episcleritis is a self-limiting disease producing little or no permanent damage to the eye.
Therefore, many, if not most, patients with episcleritis will not require any treatment. However,
some patients with mild symptoms demand treatment and may benefit from the use of artificial
tears.[11]

Occasionally, a clear history of an exogenous sensitization can be obtained, and removal

of this agent will prevent recurrent attacks.

Ocular therapy
Simple episcleritis often requires no treatment. Artificial tears are useful for patients with
mild-to-moderate symptoms. Patients with severe or prolonged episodes may require artificial
tears and/or topical corticosteroids.
Nodular episcleritis is more indolent and may require local corticosteroid drops or antiinflammatory agents.
Topical ophthalmic 0.5% prednisolone, 0.1% dexamethasone, loteprednol etabonate
0.5%, or 0.1% betamethasone daily may be used.

Systemic therapy
If nodular episcleritis is unresponsive to topical therapy, systemic anti-inflammatory agents may
be useful.
-

Flurbiprofen (100 mg tid) is usually effective until inflammation is suppressed.

If there is no response to flurbiprofen, indomethacin can be used; 100 mg daily and
decreased to 75 mg when there is a response. Naproxen 220 mg is a useful over-the-counter
(OTC) oral nonsteroidal anti-inflammatory agent (NSAID) and can be used up to 6 times per
day. Higherprescription strength naproxen 500 mg is useful for larger patients or more
severe episcleritis.
Many patients who do not respond to one NSAID may respond to another NSAID. These
agents are best given with food in order to prevent gastrointestinal side effects.

Activity
Sunglasses may be useful for patients with sensitivity to light.

Medication Summary
The goals of pharmacotherapy are to decrease pain, improve quality of life, to reduce morbidity,
and to prevent complications.[12]

Corticosteroids
Class Summary
Have anti-inflammatory properties and cause profound and varied metabolic effects.
Corticosteroids modify the body's immune response to diverse stimuli.
Dexamethasone ophthalmic (Ozurdex, Maxidex)
Suppresses the inflammatory response to a variety of agents and probably delays healing.
Used for steroid responsive inflammatory conditions of the palpebral and bulbar
conjunctiva, cornea, and anterior segment of the globe; when the inherent hazard of steroid
use is accepted; and corneal injury from chemical or thermal burns or penetration of foreign
bodies has occurred. Duration of treatment will vary from a few days to several weeks,
according to therapeutic response.
Prednisolone acetate 1% (Pred Forte, Omnipred, Pred Mild)
Sterile ophthalmic suspension that is a topical anti-inflammatory agent for treating steroid
responsive inflammation of palpebral and bulbar conjunctiva as well as cornea and anterior
segment. Shake well prior to use. Do not discontinue therapy prematurely.
Loteprednol ophthalmic (Alrex, Lotemax)
Sterile ophthalmic suspension with an ester steroid. This molecular change from the basic
steroid ring structure substitutes an ester rather than a ketone at the 20 position, thus
imparting a favorable IOP and cataractogenesis profile. This versatile agent has numerous
FDA-approved indications, including postcataract inflammation, anterior uveitis, seasonal
allergic conjunctivitis, and giant papillary conjunctivitis.

Nonsteroidal Anti-inflammatory Agents

Class Summary
Their mechanism of action is not known but may inhibit cyclooxygenase activity and
prostaglandin synthesis. Other mechanisms may exist, such as inhibition of leukotriene
synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and
various cell membrane functions.
Flurbiprofen

May inhibit cyclooxygenase enzyme, which, in turn, inhibits prostaglandin biosynthesis.

These effects may result in analgesic, antipyretic, and anti-inflammatory activities. Available
in 50- and 100-mg doses.
Indomethacin (Indocin, Tivorbex)
Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and
glucuronide conjugation; inhibits prostaglandin synthesis. For use with episcleritis that has
been nonresponsive to topical treatment.
Ibuprofen (Advil, Motrin, Addaprin, Dyspel, Provil)
Ibuprofen is usually the DOC for treating mild to moderate pain if no contraindications
exist. It is one of the few NSAIDs indicated for fever reduction.
Ketoprofen
Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are
indicated initially in small patients, elderly patients, and patients with renal or liver disease.
Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with
caution and closely observe the patients response.
Naproxen (Aleve, Anaprox, Anaprox DS, Naprelan, Naprosyn)
Naproxen is used for the relief of mild to moderate pain. It inhibits inflammatory reactions
and pain by decreasing COX activity, which results in decreased prostaglandin synthesis.
Further Outpatient Care
Approximately 30% of patients with episcleritis may have an associated underlying
systemic disease. Of these, up to 11% of patients with episcleritis may havehyperuricemia.
Other diseases with high degrees of association with episcleritis are connective tissue
disease, herpes zoster, rosacea, syphilis, underlying vasculitic disease, and atopy. Infectious
diseases other than herpes (eg, tuberculosis, syphilis, Lyme disease, bacterial infections) are
seen but are relatively uncommon.
In patients with gout, recurrent episcleritis may be associated with attacks of arthritis.
Long-term continuous therapy with steroid preparations should be avoided because of the
danger of inducing cataract and glaucoma. Also, excessive steroid use in episcleritis may
increase the risk of recurrence.

Deterrence/Prevention
In patients with gout, control uric acid levels.

Prognosis
The prognosis is favorable.

Patient Education
Episcleritis is usually self-limited. The patient is usually comforted to know that it does not
progress to a more serious disorder.

References
1.

Foster CS, Maza MS. The Sclera. Springer-Verlag; 1994. 96-102.

2.

Watson PG, Hazelman BL. The Sclera and Systemic Disorders. Philadelphia: WB
Saunders; 1976.

3.

Lin CP, Shih MH, Su CY. Scleritis. Surv Ophthalmol. 2006 May-Jun. 51(3):288-9; author
reply 289.[Medline].

4.

Watson PG. Episcleritis. Current Ocular Therapy. 5th ed. 809.

5.

Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol. 1976. 60:163192. [Medline].

6.

Yadav S, Rawal G. Tubercular Nodular Episcleritis: A Case Report. J Clin Diagn Res.
2015 Aug. 9 (8):ND01-2. [Medline].

7.

Minas TF, Podos SM. Familial glaucoma associated with elevated episcleral venous
pressure. Arch Ophthalmol. 1968. 80:202-213. [Medline].

8.

Roy FH. Ocular Differential Diagnosis. 7th ed. Baltimore: Williams & Wilkins; 2002.
Vol 1:

9.

Boniuk M. The ocular manifestations of ophthalmic vein and aseptic cavernous sinus
thrombosis. Trans Am Acad Ophthalmol Otolaryngol. 1972 Nov-Dec. 76(6):151934. [Medline].

10.

Axmann S, Ebneter A, Zinkernagel MS. Imaging of the Sclera in Patients with Scleritis
and Episcleritis using Anterior Segment Optical Coherence Tomography. Ocul Immunol
Inflamm. 2015 Aug 10. 1-6.[Medline].

11.

Williams CP, Browning AC, Sleep TJ. A randomised, double-blind trial of topical
ketorolac vs artificial tears for the treatment of episcleritis. Eye. Sep 2004. [Medline].

12.

Lim L, Suhler EB, Smith JR. Biologic therapies for inflammatory eye disease. Clin
Experiment Ophthalmol. 2006 May-Jun. 34(4):365-374. [Medline].