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CLINICAL MANAGEMENT GUIDELINES
Episcleritis
Aetiology
Idiopathic inflammation of the vascular connective tissue layer that lies
between the sclera and conjunctiva
Predisposing factors
Up to one third of cases (especially nodular variety) associated with
systemic disorders, e.g.
 collagen vascular diseases
 rheumatoid arthritis
 systemic lupus erythematosus
 inflammatory bowel disease
Also other conditions including gout, ocular rosacea
(NB importance of careful history taking)
Previous history of episcleritis
Herpes Zoster Ophthalmicus
Commonest in 4th or 5th decades
Symptoms
Acute onset
Typically unilateral red eye, but bilateral in a quarter to a half of cases
Mild ache or burning sensation
Sometimes tender on palpation
Occasionally watery
Condition commonly recurrent
Signs
Hyperaemia from dilated episcleral vessels (NB these follow a regular
radiating pattern and are immovable, unlike the finer overlying
conjunctival vessels which move freely with the conjunctiva).
Hyperaemia blanches with vasoconstrictors (e.g. gutt. phenylephrine
10%)
Simple (80%)
 sectoral or diffuse redness
Nodular (20%)
 nodule (mild elevation of the conjunctiva) with injection
Typically no anterior chamber reaction
Usually no corneal or palpebral conjunctival involvement
No effect on visual acuity
Differential diagnosis
Scleritis (see Clinical Management Guideline on Scleritis)
Conjunctivitis (viral, bacterial, allergic)
Phlyctenular keratoconjunctivitis
Anterior uveitis
Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non pharmacological
Usually self-limiting in 7-10 days
Reassurance: condition does not generally progress to more serious
ocular disorder
Cold compresses
Advise patient to return/seek further help if symptoms persist
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Pharmacological
Mild cases: no specific treatment
If discomfort: artificial tears, eg g. hypromellose or g. carmellose sodium
as necessary for 1-2 weeks
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Inconsistent evidence for benefit of topical NSAIDs (off-licence use)
(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)
Episcleritis
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Date of search 21.06.15; Date of revision 18.09.15; Date of publication 20.10.15; Date for review 20.06.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Episcleritis
More severe cases (including nodular type) may need mild topical steroid
e.g. fluorometholone for 1-2 weeks
(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)
Severe cases may benefit from systemic non-steroidal anti-inflammatory
treatment, e.g. flurbiprofen 100mg tds or naproxen 500mg bd
(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)
NB patients on topical steroids should be re-examined after 7-10 days
(including IOP measurement) (see Clinical Management Guideline on
Glaucoma [steroid])
Management Category B3: management to resolution
B1: at second recurrence (third episode), refer for investigation
Possible management by Ophthalmologist
Investigation for underlying systemic disease
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and
Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm)
Sources of evidence
Lloyd-Jones D, Tokarewicz A, Watson PG. Clinical evaluation of
clobetasone butyrate eye drops in episcleritis. Br J Ophthalmol.
1981;65(9):641-3
Lyons CJ, Hakin KN, Watson PG. Topical flurbiprofen: an effective
treatment for episcleritis? Eye (Lond). 1990;4(3):521-5
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
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. 1966;50(8):463-81
Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol
1976;60:163-91
Williams CP, Browning AC, Sleep TJ, Webber SK, McGill JI. A
randomised, double-blind trial of topical ketorolac vs artificial tears for the
treatment of episcleritis. Eye (Lond). 2005;19(7):739-42
LAY SUMMARY
Episcleritis is an inflammation of the episclera, the tissue that lies just under the outer skin of the
white of the eye. Commonest between the ages of 40 to 60, it usually affects just one eye but both
eyes are affected in a quarter to a half of cases. In about one in three of cases there is a
background of inflammation elsewhere in the body, for example rheumatoid arthritis or
inflammation of the bowel.
The condition begins without warning and patients experience redness, aching and tenderness of
one or both eyes. The vision is not affected. Episcleritis may disappear in a week to ten days and
Episcleritis
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Date of search 21.06.15; Date of revision 18.09.15; Date of publication 20.10.15; Date for review 20.06.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Episcleritis
return again later. The optometrist will reach a diagnosis based on the exact type of inflammation,
which distinguishes this condition from conjunctivitis (inflammation of the outer skin of the eye) and
scleritis (inflammation of the white part of the eyeball).
Cold compresses may relieve the symptoms, as may artificial tears in eye drop form. If the
inflammation is more severe, steroid eye drops may be prescribed, and sometimes antiinflammatory tablets are needed also.
After the second recurrence, the optometrist will normally refer the patient for investigation by the
ophthalmologist.
Episcleritis
Version 9, Page 3 of 3
Date of search 21.06.15; Date of revision 18.09.15; Date of publication 20.10.15; Date for review 20.06.17
© College of Optometrists