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

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