- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial nerve palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
Episcleritis
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Contents
Aetiology
Inflammation of the episclera (vascular connective tissue layer that lies between the sclera and conjunctiva)
Predisposing factors
Incidence 41 per 100,000 per annum
Generally idiopathic, but up to one third of cases (especially nodular variety and in bilateral cases) associated with systemic disorders, e.g.
- rheumatoid arthritis (5% develop episcleritis)
- inflammatory bowel disease
- seronegative spondyloarthropathies, e.g. ankylosing spondylitis
- vasculitides
- systemic lupus erythematosus
- relapsing polychondritis
(NB importance of careful history taking)
Previous history of episcleritis
Infections e.g. Herpes Zoster Ophthalmicus
Commonest in 4th or 5th decades
Symptoms of episcleritis
Typically unilateral red eye, but bilateral in 25-50% of cases
- Acute onset
- Mild ache or burning sensation
- Sometimes tender on palpation
- Occasionally watery
- Condition commonly recurrent
Signs of episcleritis
Hyperaemia from dilated episcleral vessels in one or more quadrants of one or both eyes. (Bilateral involvement suggests underlying systemic disease).
Hyperaemia blanches with vasoconstrictors (e.g. gutt. phenylephrine 2.5%)
Simple episcleritis (80%)
- sectoral or diffuse redness
- dilated episcleral vessels follow a regular radiating pattern and are largely immovable, unlike the finer overlying conjunctival vessels which move freely with the conjunctiva
Nodular episcleritis (20%)
- nodule (mild elevation of the conjunctiva) with injection
- in most cases, nodule within palpebral aperture
- dilated episcleral vessels are moveable as the lesion is elevated
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
Pingueculitis
Anterior uveitis
Management by optometrist
Practitioners should work within their scope of practice, 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; nodular form may persist for longer
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
If asymptomatic: no specific pharmacological treatment
If symptomatic: refrigerator cooled artificial tears as necessary for 1-2 weeks and/or oral NSAIDs e.g. Flurbiprofen.
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Inconsistent evidence for benefit of topical NSAIDs (off-label use)
(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)
More severe cases (including nodular type) may need mild topical steroid e.g. fluorometholone or loteprednol for 1-2 weeks then tapered appropriately. A baseline measurement of IOP should be taken before starting steroid therapy
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
NB patients on topical steroids should be re-examined after 7-10 days (including repeat IOP measurement) (see Clinical Management Guideline on Steroid-related OHT and Glaucoma)
Management category
B3: management to resolution
B2 (modified): episcleritis with symptoms suggestive of systemic disease, or at second recurrence (third episode), refer for investigation (referral criteria may vary between centres). It is possible that the GP may not have access to the range of blood tests required. May require rheumatology input
Possible management in secondary care or local primary/community pathways where available
Additional guidance may be available
Investigation for underlying systemic disease
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradingworkinggroup.org)
Sources of evidence
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. 2016;24(1):29-34
Daniel Diaz J, Sobol EK, Gritz DC. Treatment and management of scleral disorders. Surv Ophthalmol. 2016;61(6):702-717
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
Salama A, Elsheikh A, Alweis, R. Is this a worrisome red eye? Episcleritis in the primary care setting. J. Community Hosp. Intern. Med. Perspect. 2018;8(1):46-48
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
Summary
What is Episcleritis?
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 often disappears in a week to ten days. In some patients, it may 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).
How is Episcleritis managed?
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 anti-inflammatory tablets are needed also.
After the second recurrence, the optometrist may refer the patient for investigation by the ophthalmologist.
Last updated
Episcleritis
Version 13
Date of search 01.11.23
Date of revision 21.12.23
Date of publication 05.03.24
Date for review 31.10.25
© College of Optometrists
- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial nerve palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines