Episcleritis

Episcleritis is inflammation of the episclera. This is a thin layer of tissue between the clear surface covering of the eye, called the conjunctiva, and the firm white wall of the eye, called the sclera.

The inflammation makes part or all of the white of the eye look bright red. It usually causes mild soreness or tenderness rather than severe pain. Vision normally stays clear.

There are two main patterns. Simple episcleritis causes flat areas of redness. Nodular episcleritis causes a small, raised, tender area. Both usually settle without permanent damage, although the nodular type may last longer.

Episcleritis matters because several other conditions can also cause a red eye. Scleritis, which affects the deeper white wall of the eye, can cause severe pain and threaten sight. Infection, inflammation inside the eye, and a corneal problem can also need urgent treatment. An eye examination is therefore important when the cause of redness is uncertain.

Most episodes have no identified cause. In some people, especially those with repeated or difficult episodes, episcleritis is associated with an inflammatory condition elsewhere in the body.

The redness may affect one small section of one eye, several sections, or most of the visible white surface. One or both eyes can be involved.

Typical symptoms include:

• Bright red or pink eye tissue
• Mild aching, irritation, or a gritty feeling
• Tenderness when the eyelid or nearby eye area is touched
• Watering
• A small raised red area in nodular episcleritis

There is usually little or no discharge. Thick, sticky discharge is more suggestive of conjunctivitis or another cause.

Episcleritis should not normally cause severe pain, marked sensitivity to light, or reduced vision. These symptoms need prompt assessment because they may point to deeper inflammation, a corneal problem, glaucoma, or another eye condition.

The redness may look dramatic even when discomfort is mild. It can also improve and then return during the same episode.

In most cases, no specific cause is found. This is called idiopathic episcleritis.

Sometimes episcleritis is associated with an immune-mediated condition. This means the immune system is causing inflammation in the body's own tissues. Associated conditions can include rheumatoid arthritis, inflammatory bowel disease, lupus, and certain forms of blood-vessel inflammation called vasculitis.

Less commonly, episcleritis may occur alongside an infection. Examples include shingles and, more rarely, infections such as syphilis or tuberculosis. These possibilities are considered only when symptoms, examination findings, or personal risk factors suggest them.

Rosacea, a condition that causes facial redness and skin inflammation, can also be associated with eye-surface inflammation.

Having episcleritis does not mean that you have an autoimmune disease or infection. Most people with a single, typical episode do not need an extensive search for an underlying illness.

Further investigation is more likely to be considered if episodes are frequent, affect both eyes, do not settle as expected, or occur with symptoms elsewhere in the body. Relevant symptoms might include persistent joint swelling, unexplained rashes, mouth ulcers, bowel symptoms, or ongoing fever.

Episcleritis is diagnosed mainly through an eye examination. There is no single blood test that confirms it.

A clinician may examine the eye using a slit lamp. This is a microscope with a bright, narrow light that shows which layer of the eye is inflamed. The examination also checks the cornea, the inside of the eye, and visual sharpness.

Diluted phenylephrine eye drops may sometimes be used during the examination. These drops make the enlarged surface blood vessels become pale, or “blanch.” Episcleral vessels usually blanch, while the deeper vessels involved in scleritis do not. This test is performed in a clinical setting and is not something to try with over-the-counter redness-relief drops.

The examiner may also gently assess whether the red area is tender or raised. Severe, deep pain and a darker red or purple appearance are more concerning for scleritis.

Blood tests or other investigations are not routinely needed after a straightforward first episode. They may be arranged when the pattern suggests an associated inflammatory or infectious condition. Testing should be guided by your medical history and examination rather than using the same broad panel for everyone.

Many episodes settle on their own. Treatment is aimed at easing discomfort and controlling inflammation while making sure a more serious cause has not been missed.

Comfort measures may include:

• Cool compresses over the closed eye
• Preservative-free lubricating eye drops, also called artificial tears
• A break from contact lenses while the eye is red or uncomfortable
• Avoiding rubbing the eye

An oral non-steroidal anti-inflammatory drug, or NSAID like ibuprofen or naproxen, may be considered when discomfort or inflammation is more troublesome. These medicines are not suitable for everyone. They can affect the stomach, kidneys, heart, blood clotting, and some other medicines. A clinician or pharmacist can help determine whether this type of treatment is appropriate for you.

A short course of corticosteroid eye drops may sometimes be used for persistent or more uncomfortable inflammation. These drops need professional supervision. Steroid drops can raise pressure inside the eye, delay healing, and worsen or hide some infections. Do not use leftover steroid drops for a new red eye.

Antibiotics like amoxicillin or doxycycline do not treat ordinary episcleritis because it is not usually caused by bacteria. Drops that simply “get the red out” also do not treat the inflammation. Frequent use of these products can lead to rebound redness when their effect wears off.

If episcleritis is connected to another inflammatory or infectious condition, treatment of that condition may help control eye episodes. Care may involve an eye specialist and the clinician managing the underlying condition.

Episcleritis itself usually clears without scarring or loss of vision.

The most common longer-term problem is recurrence. Episodes may return in the same eye, the other eye, or a different part of the eye. Recurrence does not automatically mean that the condition is becoming more serious, but repeated episodes are worth discussing at a routine appointment.

Occasionally, nearby structures become inflamed. This can include the cornea, the clear front surface of the eye, or the uvea, the coloured and internal layers of the eye. New light sensitivity, blurred vision, or increasing pain needs prompt assessment.

Complications can also come from treatment. Corticosteroid eye drops may increase eye pressure or contribute to cataracts when used repeatedly or for longer periods. Monitoring reduces these risks.

Scleritis is a different and deeper condition rather than a usual stage of episcleritis. Because the two can initially look similar, worsening pain or vision changes should not be assumed to be a normal progression.

There is no reliable way to prevent most episcleritis because its cause is usually unknown.

If episodes are linked to an inflammatory condition, good control of that condition may reduce eye inflammation, but it cannot guarantee that episcleritis will not return. Treatment should follow the plan agreed for that condition.

Avoiding smoke, dust, and other irritants may improve comfort, but these steps do not prevent immune-related episcleritis. Regular handwashing can reduce the spread of infectious conjunctivitis, but ordinary episcleritis is not contagious and is not caused by poor hygiene.

Do not use steroid eye drops in an attempt to prevent another episode. They should only be used when the current red eye has been assessed and the treatment is monitored.

A typical episode improves over days and often clears within a few weeks. Nodular episodes can take longer to settle. The redness may fade gradually rather than disappearing all at once.

Vision usually remains normal, and most people can continue everyday activities. Screens and reading do not damage the eye, although taking breaks or using lubricating drops may make the eye feel more comfortable.

Contact lenses can irritate an already inflamed eye. It is generally sensible to leave them out until the redness and discomfort have cleared and any infection has been ruled out. If a lens wearer develops significant pain, light sensitivity, discharge, or blurred vision, urgent assessment is important because corneal infections can progress quickly.

Some people have one episode and never experience another. Others have occasional recurrences over months or years. Repeated episodes may lead to a review for associated health conditions, particularly if you also have joint, skin, bowel, or other inflammatory symptoms.

Episcleritis does not usually cause progressive loss of sight. However, each new red-eye episode should not automatically be assumed to be episcleritis, especially if the symptoms feel different from before.

Arrange a routine eye examination if this is your first unexplained episode of eye redness, if the redness keeps returning, or if it is not improving as expected. Routine follow-up is also appropriate if episodes affect both eyes or occur with ongoing joint swelling, rashes, bowel symptoms, mouth ulcers, or other signs of inflammation.

Seek urgent same-day assessment if you have:

• Moderate or severe eye pain
• Reduced, blurred, or distorted vision
• Marked sensitivity to light
• A dark red or purple area on the white of the eye
• A painful red eye while wearing contact lenses
• Increasing redness or swelling
• Recent eye surgery or an eye injury
• Headache, nausea, or coloured halos around lights with a red eye

A chemical splash to the eye is an emergency. Rinse the eye immediately with plenty of clean lukewarm water and seek emergency help. Do not wait for redness or pain to develop.

Sudden vision loss, major eye trauma, or a foreign object embedded in the eye also requires emergency care.

Is episcleritis contagious?

No. Ordinary episcleritis cannot spread from one person to another. A red eye caused by viral or bacterial conjunctivitis may be contagious, which is one reason a new red eye sometimes needs examination.

How long does episcleritis last?

Many episodes settle within several days to a few weeks. Nodular episcleritis may last longer. Persistent, worsening, or repeatedly returning redness should be reviewed.

What is the difference between episcleritis and scleritis?

Episcleritis affects a surface tissue layer and usually causes mild discomfort with normal vision. Scleritis affects the deeper white wall of the eye and more often causes severe, deep pain. Scleritis can threaten vision and needs urgent specialist care.

Can stress cause episcleritis?

Some people notice episodes during stressful periods, but stress has not been established as a direct cause. Most cases do not have a clear trigger. Do not assume stress explains severe pain or changes in vision.

Can I wear contact lenses or eye makeup?

It is usually more comfortable to avoid contact lenses and eye makeup while the eye is red or sore. Restart them after symptoms have cleared and any infection has been ruled out. Replace products or lens equipment if a clinician thinks contamination may be involved.

Will episcleritis come back?

It can. Some people never have another episode, while others have recurrences over months or years. A change in the type of pain, vision, or sensitivity to light should be assessed rather than treated as a familiar episode.