Episcleritis is typically a transient (usually days to weeks), self-limited disease of sudden onset affecting adults aged 20–50 years, with most cases occurring in women. The patient’s chief concern is usually ocular redness with irritation or pain. Slight tenderness may occur. The disease occurs most often in the exposed interpalpebral zone of the eye, in the area of a pinguecula. It may recur in the same or different locations. About one-third of patients have bilateral disease at one time or another.
Episcleritis is classified as simple (diffuse injection) or nodular. In simple episcleritis, the inflammation is localized to a sector of the globe in 70% of cases and to the entire episclera in 30% of cases. A localized mobile nodule develops in nodular episcleritis (Fig 11-20). Small peripheral corneal opacities can be observed adjacent to an area of episcleral inflammation in 10% of patients.
Figure 11-20 Nodular episcleritis.
Episcleral inflammation is superficial and will blanch with application of topical phenylephrine 2.5%. Episcleritis must be differentiated from the deeper inflammation seen in scleritis (often with associated scleral edema clearly discernible on slit-lamp examination). The inflamed episclera is characteristically bright red or salmon pink in natural light, unlike the violaceous hue seen in most forms of scleritis.
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.
A workup for underlying causes (eg, autoimmune connective tissue disease such as Sjögren syndrome or rheumatoid arthritis; other conditions such as gout, herpes zoster, syphilis, tuberculosis, Lyme disease, or rosacea) is rarely indicated except after multiple recurrences. Episcleritis generally clears without treatment, but topical or oral NSAIDs may be prescribed for patients bothered by the pain. Most patients simply need reassurance that their condition is not sight threatening and can be treated with lubricants alone. Topical corticosteroid use should be kept to a minimum in this benign, self-limited condition. In cases that do not respond to lubricants and NSAIDs, a course of topical corticosteroids may be necessary and beneficial.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.