eMedicine Specialties > Ophthalmology > Sclera

Episcleritis

Author: Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Contributor Information and Disclosures

Updated: Jun 18, 2009

Introduction

Background

Episcleritis is an inflammatory condition affecting the episcleral tissue that lies between the conjunctiva and the sclera. Episcleritis is usually a mild, self-limiting, recurrent disease. Most cases are idiopathic, although up to one third have an underlying systemic condition. Some cases may be caused by exogenous inflammatory stimuli.

Pathophysiology

The pathophysiology is poorly understood. The inflammatory response is localized to the superficial episcleral vascular network, and histopathology shows nongranulomatous inflammation with vascular dilatation and perivascular infiltration.

The 2 clinical types are simple and nodular.

The most common type is simple episcleritis, in which there are intermittent bouts of moderate-to-severe inflammation that often recur at 1- to 3-month intervals. The episodes usually last 7-10 days, and most resolve after 2-3 weeks. Prolonged episodes may be more common in patients with associated systemic conditions. Some patients note that episodes are more common in the spring or fall. The precipitating factor is rarely found, but attacks have been associated with stress and hormonal changes.

Patients with nodular episcleritis have prolonged attacks of inflammation that are typically more painful than simple episcleritis. Many patients with nodular episcleritis have an associated systemic disease.

Frequency

United States

True frequency is difficult to determine since many patients do not seek medical attention.

Sex

Some authors report no difference, while other authors report that up to 74% of cases occur in females.

Age

Episcleritis is most common in the fourth to fifth decades.

Clinical

History

All patients should undergo a thorough history, including a review of systems.

• Many patients complain of acute onset of mild-to-moderate discomfort, although some may notice an area of painless injection.
• Photophobia and watery discharge may be noted.

Physical

• A diffuse or localized injection of the bulbar conjunctiva is often present.
• A watery discharge is observed in some patients.
• A freely moveable nodule may be present in nodular episcleritis.
• Corneal findings are uncommon and include dellen formation as well as peripheral corneal infiltrates.
• An associated anterior uveitis may occur in as many as 10% of patients.

Causes

Most cases are idiopathic; however, up to one third of cases may have an underlying systemic condition.

• Collagen vascular diseases  
  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Polyarteritis nodosa
  • Seronegative spondyloarthropathies -Ankylosing spondylitis, inflammatory bowel disease, reactive arthritis, psoriatic arthritis
• Miscellaneous  
  • Gout
  • Atopy
  • Foreign bodies
  • Chemicals
• Infectious diseases  
  • Bacteria, including tuberculosis, Lyme disease, and syphilis
  • Viruses, including herpes
  • Fungi
  • Parasites
• Other rare causes/associations  
  • T-cell leukemia
  • Paraproteinemia
  • Paraneoplastic syndromes - Sweet syndrome, dermatomyositis
  • Wiskott-Aldrich syndrome
  • Adrenal cortical insufficiency
  • Necrobiotic xanthogranuloma
  • Progressive hemifacial atrophy
  • Following transscleral fixation of posterior chamber intraocular lens
  • Insect bite granuloma
  • Malpositioned Jones tube

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