Episcleritis

Symptoms

acute or rapid onset of redness (one or both eyes)

mild discomfort or foreign body sensation

no discharge and no photophobia

typically affects young-to-middle-aged adults; more common in women

frequent history of recurrent episodes

Clinical Findings

Clinical types

• simple (sectoral or diffuse): salmon-pink redness of the superficial episcleral plexus
• nodular: discrete, mobile, elevated pink nodule; more symptomatic and tender

Differentiation (phenylephrine test)

• episcleritis: superficial vessels blanch (redness fades) within 10–15 minutes
• scleritis: deep vessels do not blanch; violaceous hue and engorgement persist

Mechanical signs

• cotton-swab test: superficial vessels move freely over the underlying sclera
• pain: mild discomfort only (unlike the severe boring pain of scleritis)
• vision, pupils, and anterior chamber are typically normal

Etiology

Idiopathic

• ~70% of cases; most patients have no underlying systemic disease

Systemic associations

• autoimmune: rheumatoid arthritis, sle, inflammatory bowel disease, ankylosing spondylitis, vasculitis
• skin/metabolic: rosacea, atopy, gout
• infectious: herpes zoster, syphilis

Medications

• topiramate
• pamidronate

Red Flags

progression to scleritis: severe pain that radiates or wakes the patient at night

deep scleral vessels that fail to blanch with phenylephrine 2.5%

recurrent bilateral episodes suggesting underlying systemic disease

failure to improve with standard topical therapy

Investigations

Slit lamp evaluation

• phenylephrine 2.5% test: assess for blanching of superficial vs deep vessels
• cotton-swab test: check for vessel mobility over the sclera
• comprehensive exam: rule out corneal or anterior chamber involvement

Systemic screening (for recurrent or nodular cases)

• labs: cbc, cmp, esr, crp, ana, rf, anti-ccp, and uric acid
• infectious: rpr, vdrl, and treponemal-specific assays
• specific markers: anca (vasculitis) or hla-b27 (if joint symptoms present)

Treatment

Initial management

• chilled artificial tears 4x daily and cold compresses
• reassurance: most simple cases resolve spontaneously in 1–2 weeks

Pharmacology

• oral nsaids: ibuprofen 400–600 mg 3x daily with food
• topical nsaids as an adjunct for persistent symptoms
• topical steroids: short course of weak steroids (e.g., loteprednol or fluorometholone) for refractory cases

Systemic coordination

• treat underlying rosacea or gout; refer to rheumatology if autoimmune workup is positive

Differential Diagnosis

• scleritis (deep boring pain, non-blanching vessels)
• conjunctivitis (discharge, follicles/papillae)
• iritis (photophobia, ac cell/flare)
• contact lens-related irritation

Related Sclera Conditions

• Scleritis