History

Fact Explanation
Eye discomfort. Due to the inflammation of the episcleral tissue [1].
Red eye. Due to the engorgement of the superficial episcleral plexus [2].
Photophobia and tearing. These symptoms correlate with corneal changes but may also indicate a necrotizing process [3].
History of morning stiffness and pain in small peripheral joints, occurring in bilaterally symmetrical distribution. Episcleritis is associated with rheumatoid arthritis due to the widespread vasculitis [4].
History of asthma or hay fever. Episcleritis is associated with atopy [3].
History of genital lesions or multiple sexual partners. Syphilis can lead to inflammation in any area of the globe [5].
References
  1. MUELLER JORMA B., MCSTAY CHRISTOPHER M.. Ocular Infection and Inflammation. Emergency Medicine Clinics of North America [online] 2008 February, 26(1):57-72 [viewed 02 July 2014] Available from: doi:10.1016/j.emc.2007.10.004
  2. MAHMOOD AHMED R., NARANG ANEESH T.. Diagnosis and Management of the Acute Red Eye. Emergency Medicine Clinics of North America [online] 2008 February, 26(1):35-55 [viewed 02 July 2014] Available from: doi:10.1016/j.emc.2007.10.002
  3. WATSON P. G., HAYREH S. S.. Scleritis and episcleritis.. British Journal of Ophthalmology [online] 1976 March, 60(3):163-191 [viewed 02 July 2014] Available from: doi:10.1136/bjo.60.3.163
  4. MCGAVIN DD, WILLIAMSON J, FORRESTER JV, FOULDS WS, BUCHANAN WW, DICK WC, LEE P, MACSWEEN RN, WHALEY K. Episcleritis and scleritis. A study of their clinical manifestations and association with rheumatoid arthritis. Br J Ophthalmol [online] 1976 Mar, 60(3):192-226 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1042707
  5. YOON KYUNG-CHUL, IM SEONG-KYU, SEO MAN-SEONG, PARK YEOUNG-GEOL. Neurosyphilitic episcleritis. [online] 2005 March, 83(2):265-265 [viewed 02 July 2014] Available from: doi:10.1111/j.1600-0420.2005.00394.x

Examination

Fact Explanation
Diffuse or localized bulbar conjunctival injection. Due to the engorgement of the superficial episcleral plexus [1].
Watery discharge. It correlates with corneal changes but may also indicate a necrotizing process [2].
A mobile nodule in the sclera. These are focal areas of dilated blood vessels and occur in nodular episcleritis [1].
Peripheral corneal infiltrates. Due to an extension of localised scleral oedema into the cornea [3].
Congested episcleral vessels which run radially and are salmon pink in color, detected on slit lamp examination of the eye. Dilatation of the different plexuses of vessels are easily identified on slit-lamp examination. The slit-lamp detects the depth of maximum vascular congestion and site of oedema, thus allowing episcleritis to be distinguished from scleritis [4].
References
  1. MAHMOOD AHMED R., NARANG ANEESH T.. Diagnosis and Management of the Acute Red Eye. Emergency Medicine Clinics of North America [online] 2008 February, 26(1):35-55 [viewed 02 July 2014] Available from: doi:10.1016/j.emc.2007.10.002
  2. WATSON P. G., HAYREH S. S.. Scleritis and episcleritis.. British Journal of Ophthalmology [online] 1976 March, 60(3):163-191 [viewed 02 July 2014] Available from: doi:10.1136/bjo.60.3.163
  3. WATSON P, BOOTH-MASON S. Fluorescein angiography in the differential diagnosis of sclerokeratitis.. British Journal of Ophthalmology [online] 1987 February, 71(2):145-151 [viewed 02 July 2014] Available from: doi:10.1136/bjo.71.2.145
  4. LACHMANN SM, HAZLEMAN BL, WATSON PG. Scleritis and associated disease. Br Med J [online] 1978 Jan 14, 1(6105):88-90 [viewed 03 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1602644

Differential Diagnoses

Fact Explanation
Scleritis. It also presents with red eye, but the presence of pain as opposed to discomfort, the vascular pattern, and the appearance of scleral transparency distinguish it from episcleritis [1].
Viral conjunctivitis. It also presents with red eye, but usually begins with irritation in one eye which spreads to the other a few days later. Some patients may have an associated upper respiratory tract infection [2].
Keratitis. It presents with an acutely red, painful eye and the patient complains of foreign body sensation and change in vision [3].
References
  1. LYNE A. J.. Corneal sensation in scleritis and episcleritis.. British Journal of Ophthalmology [online] 1977 October, 61(10):650-654 [viewed 02 July 2014] Available from: doi:10.1136/bjo.61.10.650
  2. MAHMOOD AHMED R., NARANG ANEESH T.. Diagnosis and Management of the Acute Red Eye. Emergency Medicine Clinics of North America [online] 2008 February, 26(1):35-55 [viewed 02 July 2014] Available from: doi:10.1016/j.emc.2007.10.002
  3. MUELLER JORMA B., MCSTAY CHRISTOPHER M.. Ocular Infection and Inflammation. Emergency Medicine Clinics of North America [online] 2008 February, 26(1):57-72 [viewed 02 July 2014] Available from: doi:10.1016/j.emc.2007.10.004

Investigations - for Diagnosis

Fact Explanation
No investigations needed in the majority. Episcleritis is of idiopathic origin in two thirds of cases and usually improves after 1 week [1].
References
  1. MUELLER JORMA B., MCSTAY CHRISTOPHER M.. Ocular Infection and Inflammation. Emergency Medicine Clinics of North America [online] 2008 February, 26(1):57-72 [viewed 02 July 2014] Available from: doi:10.1016/j.emc.2007.10.004

Investigations - Screening/Staging

Fact Explanation
Serum uric acid levels. It is elevated in gout which is known to be associated with episcleritis [1].
Rheumatoid factor in blood. It is positive in rheumatoid arthritis which is known to be associated with episcleritis [2].
antinuclear antibody levels in serum. It is positive in Systemic lupus erythematosus which is known to be associated with episcleritis [3].
Chest X ray. To exclude Tuberculosis and Sarcoidosis which are known associations of episcleritis [1].
Venereal Disease Research Laboratory (VDRL) test. To exclude syphilis which is a known association of episcleritis [1].
References
  1. WATSON P. G., HAYREH S. S.. Scleritis and episcleritis.. British Journal of Ophthalmology [online] 1976 March, 60(3):163-191 [viewed 02 July 2014] Available from: doi:10.1136/bjo.60.3.163
  2. MCGAVIN DD, WILLIAMSON J, FORRESTER JV, FOULDS WS, BUCHANAN WW, DICK WC, LEE P, MACSWEEN RN, WHALEY K. Episcleritis and scleritis. A study of their clinical manifestations and association with rheumatoid arthritis. Br J Ophthalmol [online] 1976 Mar, 60(3):192-226 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1042707
  3. FRITH P, BURGE S M, MILLARD P R, WOJNAROWSKA F. External ocular findings in lupus erythematosus: a clinical and immunopathological study.. British Journal of Ophthalmology [online] 1990 March, 74(3):163-167 [viewed 02 July 2014] Available from: doi:10.1136/bjo.74.3.163

Management - General Measures

Fact Explanation
Artificial tears.(It is all that is needed in simple episcleritis.) It acts as an ocular lubricant and provides relief from the discomfort in the eye [1].
Avoid close contact with agents known to cause exogenous sensitization. Atopy is known to be associated with episcleritis [2].
References
  1. WILLIAMS C P R, BROWNING A C, SLEEP T J, WEBBER S K, MCGILL J I. A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis. Eye [online] December, 19(7):739-742 [viewed 02 July 2014] Available from: doi:10.1038/sj.eye.6701632
  2. WATSON P. G., HAYREH S. S.. Scleritis and episcleritis.. British Journal of Ophthalmology [online] 1976 March, 60(3):163-191 [viewed 02 July 2014] Available from: doi:10.1136/bjo.60.3.163

Management - Specific Treatments

Fact Explanation
Prednisolone acetate 1% ophthalmic solution. Dose: 1-2 drops twice a day. Gradual dose reduction is necessary before discontinuing treatment. (It is required in nodular episcleritis) It suppresses the inflammation in episcleritis [1].
Flurbiprofen. Dose: 100 mg three times a day. (If nodular episcleritis is unresponsive to topical therapy) Inhibits prostaglandin mediated ocular inflammation [2].
References
  1. 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 [online] 1966 Aug, 50(8):463-481 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC506254
  2. PODOS SM. Prostaglandins, nonsteroidal anti-inflammatory agents and eye disease. Trans Am Ophthalmol Soc [online] 1976:637-660 [viewed 03 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1311530