What is Episcleritis?

Episcleritis is an inflammatory condition that affects the episclera, a thin layer of tissue located between the transparent conjunctiva and the white sclera of the eye. The red appearance of the eye results from the inflammation of the episcleral tissue. It most commonly affects young individuals and typically presents with a sudden onset of ocular irritation, often described as a slight burning or gritty sensation. The blood vessels in the episclera enlarge due to the inflammation, giving the eye a reddish appearance. While episcleritis often resolves on its own within a few weeks and typically does not cause vision problems, medical assessment is essential to differentiate it from potentially more serious eye disorders and manage any associated discomfort.

Although there are no specific prevalence or incidence rates recorded for the Indian population, a 2013 study in other parts of Asia reported an incidence rate of 41 per 100,000 persons for episcleritis. The study also found that females between the ages of 25-40 years were at a higher risk of developing episcleritis.

Types of Episcleritis

1. Simple Episcleritis:  In simple episcleritis, the affected eye appears red with no significant additional signs. Symptoms may include a mild gritty sensation and mild pain. The redness is typically diffuse, resembling conjunctivitis.
2. Sectoral Episcleritis: As the name suggests, only one sector of the eye is red due to episcleritis. Symptoms are similar to diffuse episcleritis.
3. Nodular Episcleritis: Nodular episcleritis presents with sectoral redness and the development of a small inflamed nodule. This nodule can be mildly to moderately painful upon blinking. Additionally, nodular episcleritis may cause a sensation of foreign bodies in the eye due to mild dryness caused by uneven spreading of the tear film over the ocular surface.

Causes of Episcleritis

1. Idiopathic: Most cases of episcleritis are idiopathic, meaning the exact cause cannot be determined. Your eye doctor may conduct tests to identify systemic diseases, but if all tests are normal, it remains classified as idiopathic.
2. Autoimmune systemic Diseases:  Autoimmune systemic diseases, where the body’s immune system mistakenly attacks its own cells, can lead to episcleritis. Common autoimmune diseases associated with episcleritis include rheumatoid arthritis and psoriatic arthritis, accounting for 26-36% of cases. Other autoimmune conditions like inflammatory bowel disease and ulcerative colitis may also be linked to episcleritis. In some cases, episcleritis can be idiopathic but has been associated with anxiety disorders.
3. Infectious Diseases: Any infection affecting the eye, whether ocular or systemic, can lead to episcleritis as an inflammatory response. Tuberculosis is a common systemic infection associated with episcleritis. When identified, treatment is provided for both the underlying infection and episcleritis.

Signs and Symptoms of Episcleritis:

• Acute onset of redness
• Watery eyes
• Grittiness
• Discomfort in the affected eye (not typically severe pain)
• Sensitivity to light, especially bright light
• Decreased visual acuity is rare unless there is severe inflammation, as seen in scleritis

Additionally, in this eye condition, there can be multiple attacks of inflammation noted which makes this a concurrent eye disease. Recurrent episodes of scleritis and episcleritis suggests a strong systemic disease

Diagnosis of Episcleritis:

To make the episcleritis diagnosis, your eye doctor will obviously do a thorough eye exam including vision check and looking at your eye through an instrument called slit lamp biomicroscopy. Eye doctors are trained to differentiate the pattern of red eye to reach a diagnosis.

• Phenylephrine test: Your eye doctor might put an eyedrop that contains phenylephrine which is a vasoconstrictor and reacts on episcleral vessels after 10 – 15 minutes after installation. If the redness of the eye reduces/goes away, due to the constriction of episcleral vessels caused by phenylephrine, thus confirming the diagnosis of episcleritis. This test helps the eye doctor to differentiate between episcleritis redness and scleritis redness.
• Certain blood investigation may be prescribed to rule out an infectious or autoimmune cause of episcleritis and then it can be managed accordingly.
• In episcleritis, the superficial vessels of episclera are inflamed with absence of sticky discharge, where as in conjunctivitis, the conjunctival vessels are inflamed and there is sticky discharge. That’s how the eye care practitioner will distinguish the redness of these two conditions.

Treatment of Episcleritis:

Often episcleritis is a self limiting condition, i.e. it subsides on its own however, patients generally visit the eye doctors because the redness is cosmetically bothering and also sometimes there are other symptoms as described earlier, thus your eye doctor may manage it in one of the following way:

• Topical steroid eye drops (Topical corticosteroid eye drops)
• Nonsteroidal anti-inflammatory drugs (NASIDs)
• Artificial tears eye drops
• Applying cold compress to the affected eye.

In the early stage of episcleritis with nil to minimal symptoms, NSAIDs can be prescribed. However, topical steroids are more potent in managing inflammatory conditions. If the inflammation continues even after a short course of NSAIDs, the patient is switched to topical steroids. Rarely oral steroids are prescribed as episcleritis is a self limiting condition. Whenever topical steroids are prescribed, it has to be tapered over a course of time because, if stopped abruptly, an infective condition may flare up, thus, beware before self medicating with topical steroids. It’s always prudent to visit the eye care practitioner before starting any eye drops to treat episcleritis.

Difference Between Scleritis and Episcleritis:

Another common condition similar to episcleritis is scleritis. Both scleritis and episcleritis are inflammatory conditions that damage the eye’s outer layers, although they are distinct from one another in terms of clinical features like severity, signs, and underlying causes. The episclera, a thin layer of tissue between the conjunctiva and the sclera, becomes inflamed in episcleritis, a milder illness. Localized redness, some discomfort, and self-limitation are typical symptoms. Scleritis, on the other hand, is a more severe and uncomfortable condition that involves inflammation of the sclera and the vascular network of sclera, the white layer covering the outside of the eye.

Scleritis frequently co-occurs with autoimmune conditions like systemic lupus erythematosus and rheumatoid arthritis, and it can result in more severe symptoms including excruciating eye pain, blurred vision, and even consequences that could endanger one’s vision. Incidence of episcleritis is more common as compared to scleritis. For a proper diagnosis and course of treatment, it’s critical to distinguish between these disorders since scleritis calls for immediate medical attention due to the possibility of catastrophic complications. In both of these conditions, there could be an underlying systemic condition which needs to be treated subsequently. 

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