What Is Episcleritis?

Patients usually notice a patch of the white of one eye that has turned pink or red, sometimes seemingly overnight, and they worry it looks alarming even though it may barely hurt. They want to know whether it is contagious like pink eye, whether it is serious, and whether they need treatment. The reassurance many are looking for is real: episcleritis usually looks worse than it is.

The episclera is a thin, vascular layer of connective tissue sitting between the clear conjunctiva on the surface and the tough white sclera underneath. When it inflames, its small blood vessels dilate, producing a pink or red patch, often in one sector of the eye, with a mild scratchy or gritty sensation and sometimes slight tenderness when you touch that spot. Vision is not affected.

The reassuring part is that this is a superficial, self-limited process. It does not thin or damage the eye wall the way scleritis can, and it typically settles without any lasting effect. Its importance lies mostly in telling it apart from scleritis, which inflames the deeper sclera, hurts severely, and can threaten the eye. That distinction is straightforward for an eye doctor and shapes how much, if any, treatment is needed.

Episcleritis is common, tends to affect younger and middle-aged adults, and is more frequent in women. It comes in two forms: simple episcleritis, a diffuse or sectoral redness that comes and goes, and nodular episcleritis, where a small, tender, movable bump forms over the sclera and tends to last a bit longer. Most cases are idiopathic, meaning no cause is found, and they resolve on their own.

While the majority are benign and isolated, a minority are associated with systemic conditions, the same autoimmune diseases that cause scleritis, including rheumatoid arthritis, inflammatory bowel disease, and gout, or occasionally an infection. This association is much weaker than with scleritis, so a single episode in an otherwise well person rarely warrants an extensive workup; recurrent or persistent episcleritis is more likely to prompt a search for an underlying cause. The natural course is favorable: episodes usually fade within one to two weeks, though they can recur over time.

Episcleritis itself is usually benign, but a red eye should be reassessed if the picture does not fit. Seek prompt evaluation if you have:

• Deep, severe, or boring pain, especially pain that wakes you at night (this suggests scleritis, not episcleritis).
• Marked light sensitivity, blurred or reduced vision, or a bluish, thinned-looking area of the white of the eye.
• Redness that keeps recurring or does not resolve, which may prompt a look for an underlying condition.

The point is to make sure a more serious inflammation, such as scleritis or uveitis, is not being mistaken for benign episcleritis.

The main task is to confirm the inflammation is superficial and rule out scleritis. At the slit lamp, the doctor examines the depth of the inflamed vessels and the level of tenderness; a phenylephrine drop is often used, because it blanches the superficial episcleral vessels of episcleritis while the deep vessels of scleritis stay red. Vision, light sensitivity, and the inside of the eye are checked to exclude scleritis and uveitis. Because a single episode is usually benign, a systemic workup is generally reserved for episcleritis that is recurrent, persistent, or accompanied by symptoms of an autoimmune disease.

Because episcleritis is self-limited, many cases need nothing more than reassurance and time. For comfort, artificial tears and cool compresses help, and a short course of a mild topical anti-inflammatory (such as a weak steroid or a topical NSAID) can speed relief of a more bothersome or nodular episode; these are used briefly and under supervision to avoid the side effects of longer steroid use. Recurrent episcleritis linked to a systemic condition is best managed by treating that underlying disease. Unlike scleritis, episcleritis does not require aggressive systemic immunosuppression.

• Do not assume every red eye is harmless episcleritis; deep severe pain, light sensitivity, or vision change point to something more serious.
• Do not rely on over-the-counter redness-removing drops, which only mask the redness and do not treat the inflammation.
• Do not use leftover steroid drops on your own or for prolonged periods, since unsupervised steroids can raise eye pressure and cause other problems.
• Do not ignore episcleritis that keeps returning, as recurrence may point to an underlying condition worth checking.

Call for an evaluation if you have a red patch on the white of your eye that is not clearing, keeps returning, or is uncomfortable, and seek prompt care if the eye becomes deeply or severely painful, light-sensitive, or your vision changes, since that suggests a more serious inflammation. May Eye Care Center, serving the Hanover, Pennsylvania area, can confirm whether the inflammation is the benign, superficial kind and guide simple treatment.

Episcleritis is a mild, usually benign, self-limited inflammation of the thin layer over the white of the eye that rarely threatens vision, but a red eye with deep pain, light sensitivity, or vision change should be examined promptly to rule out the more serious scleritis.