A 64-year-old woman presents with a two-week history of a sore, red right eye. She describes it as a foreign-body sensation. There is no mucous discharge. On direct questioning, the vision has not changed.
She had an uncomplicated cataract operation in the same eye six months ago. She has hypertension and type 2 diabetes – and regular medication includes gliclazide and bisoprolol. She has no other significant medical history.
On examination, her best-corrected visual acuity is 6/6 in each eye. The eyelids are normal. There is sectoral inflammation of the bulbar conjunctiva, but the rest of the bulbar conjunctiva is white and normal. Deep scleral blood vessels are not engorged. Palpation of the globe is non-tender.
The tarsal conjunctiva has no papillae or follicles. The cornea is clear and the anterior chamber is quiet. There is no staining with fluorescein.
The pupil reacts to light and is equal in size to the left eye. Dilated examination is not necessary, but undilated fundal check demonstrates a normal retina and optic disc (see video, below).
The patient is diagnosed with right episcleritis.
Episcleritis is a common, benign inflammation of the episclera and is often self-limiting without treatment.1
It occurs frequently in young women and is rarely associated with connective tissue disease. It is mainly a unilateral disease, but can be bilateral. It can be recurrent.
• Acute onset of mild discomfort, often described as a foreign body sensation
• Can be associated with watery discharge and photophobia
• Sectoral inflammation of the episclera
• Normal sclera, cornea and anterior chamber2
• Can last for four to six weeks and is self-limiting without treatment in simple cases
• Non-tender globe on palpation.
• Sectoral acute, anterior scleritis – moderate to severe pain with deep vessel inflammation of the sclera, and tender globe on palpation
• Sectoral keratitis – moderate to severe pain with corneal opacity or foreign body
• Check visual acuity with correction if necessary – this will be unaffected.
• Check pupils are equal in size and light reaction, with no relative afferent papillary defect – this will be unaffected.
• Examine cornea and anterior chamber for haze or opacities – the cornea and anterior chamber will be clear with a good view of the iris.
• Instill fluorescein drops to exclude corneal defects – any changes may
suggest a sectoral keratitis rather than episcleritis.
• Exclude systemic disease in patients where it is suspected from the history.3
You can do an optional test using a topical vasoconstrictor, but only if you are confident in your knowledge of topical medications and their side-effects.
Episcleral inflammation blanches with topical vasoconstrictors, such as 2.5% phenylephrine.
It will not blanch in the presence of scleritis, where deep blood vessels are engorged.
• Simple cases can be treated and managed in primary care.
• Recurrence or bilateral cases should be referred routinely.
• Severe pain is unusual and should be referred urgently.
• Any visual loss should also be referred.
• Refer to a rheumatologist if there are any suggestions of connective tissue disease or other systemic disease.
Treatment includes reassurance that it is often self-limiting, simple cold compresses and analgesia.
Ocular lubricants can relieve the foreign-body sensation.
A one-week course of regular, simple, oral NSAIDS such as ibuprofen is helpful, as long as there are no contraindications. Topical NSAIDS tds, such as ketorelac 0.3%, can be used for up to one month, although the evidence is controversial.4
Recurrent or severe episcleritis may require stronger oral NSAIDS.
Miss Claire Daniel is a consultant ophthalmic surgeon and Mr John Bladen is a specialist registrar at Moorfields Eye Hospital, London
1 Kirkwood BJ and Kirkwood RA. Episcleritis and scleritis. Insight 2010;35:5-8
2 Jabs DA, Mudun A, Dunn JP et al. Episcleritis and scleritis: clinical features and treatment results. Am J Ophthalmol 2000;130:469-76
3 Read RW, Weiss AH and Sherry DD. Episcleritis in childhood. Ophthalmology 1999;106:2377-9
4 Williams CP, Browning AC, Sleep TJ et al. A randomised, double-blind trial of topical ketorolac versus artificial tears for the treatment of episcleritis. Eye 2005;19:739-42