Eyes & Vision

Episcleritis

Episcleritis is usually self-limiting inflammation of the superficial episclera, causing a sectoral or diffuse red eye with mild aching and preserved vision; its key clinical task is to exclude the painful, potentially sight-threatening deep inflammation of scleritis.

In a nutshell

Episcleritis is usually idiopathic, self-limiting superficial episcleral inflammation causing a sectoral/diffuse red eye, mild ache or irritation and preserved vision. Confirm that there is no severe deep pain, visual reduction, corneal/anterior-chamber disease or fixed violaceous redness suggesting scleritis. Use cold compresses and artificial tears; topical steroid and/or oral NSAID treatment is clinician-led for more troublesome disease, with recurrent or systemic cases investigated.

Classic presentation

A young or middle-aged adult develops a sectoral red patch with mild aching or grittiness, normal vision and no discharge; the superficial vessels are mobile or blanch with appropriate testing.

Key points

Episcleritis is superficial and usually preserves vision; scleritis is deeper, painful and potentially sight-threatening.
Assess visual acuity, pupil, cornea and anterior chamber, not just the redness.
Superficial vessels may move or blanch; fixed, non-blanching, violaceous inflammation raises concern for scleritis.
Cold compresses and artificial tears are first-line; topical steroid or oral NSAID treatment is reserved for more severe/persistent disease and needs clinical safety checks.
Most episodes settle in about a week to ten days, but recurrence is common; after a second recurrence or with systemic features arrange specialist/systemic assessment.

First-line investigation

Slit-lamp red-eye assessment with visual acuity, pupil, cornea and anterior-chamber examination, plus mobility/vasoconstrictor assessment where appropriate.

Management

Exclude scleritis and sight-threatening red eye

Severe deep pain, marked tenderness, non-blanching/violaceous redness, reduced vision, corneal/anterior-chamber signs or raised pressure needs urgent ophthalmic assessment.^1,2,3

Reassure and relieve symptoms

For typical episcleritis, explain the benign self-limiting course and use cold compresses and artificial tears; most episodes settle within about a week to ten days.^1,2

Use anti-inflammatory treatment selectively

For severe/persistent inflammation, topical corticosteroid and/or oral NSAID treatment may be prescribed by an eye-care clinician after infection, pressure and medicine-specific risks are checked.^1,5

Investigate recurrent or atypical disease

After a second recurrence, or earlier for bilateral/severe/atypical disease or systemic inflammatory symptoms, arrange ophthalmic review and targeted systemic assessment rather than repeated unsupervised treatment.^1,4

Exam traps

Severe deep boring pain or visual reduction is not typical episcleritis; suspect scleritis or another urgent red-eye diagnosis.
A red patch alone does not establish episcleritis; examine the cornea and anterior chamber.
Do not start steroid eye drops in an undiagnosed red eye or when infection has not been excluded.
A single typical episode does not require a broad autoimmune screen; recurrence, bilaterality, severity or systemic symptoms change the threshold.
Episcleritis can recur but should not be used to explain worsening pain, non-blanching redness or visual change.

Illustrations

Sectoral episcleritisClinical photograph of localised superficial redness on the white of the eye with an otherwise clear cornea; label it as an illustrative image and include a reminder to check vision, pain severity and the anterior chamber.Asagan, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.