Ophthalmology - Episcleritis, Scleritis

Question 1

Episcleritis - what is it?

Answer 1

Episcleritis is benign and self-limiting inflammation of the episclera, the outermost layer of the sclera

The episclera is situated just underneath the conjunctiva

Question 2

Episcleritis - how does it present?

Answer 2

Presents with acute unilateral symptoms

• Typically not painful (in comparison to scleritis) but there can be mild pain
• Red eye - segmental redness (rather than diffuse), usually in lateral sclera
• Foreign body sensation
• Dilated episcleral vessels
• Watering of eye
• No discharge

Question 3

Episcleritis - management?

Answer 3

Self-limiting (recover 1-4 weeks) - maybe some cold compresses

Artificial tears may be used

Severe cases - systemic NSAIDs (e.g. naproxen) or topical steroid eye drops

Question 4

Scleritis - what is it?

Answer 4

Scleritis involves inflammation of the full thickness of the sclera

More serious than episcleritis

Question 5

Scleritis - what is the most severe type of scleritis?

Answer 5

Necrotising scleritis

Most patients with necrotising scleritis have visual impairment but may not have pain, lead to perforation of the sclera

This is the most significant complication of scleritis

Question 6

Scleritis - what are the associated systemic conditions?

Answer 6

• RA
• SLE
• IBD
• Sarcoidosis
• Granulomatosis with polyangiitis

Question 7

Scleritis - what are the clinical features?

Answer 7

Scleritis usually presents with an acute onset of symptoms

• red eye
• classically painful (in comparison to episcleritis), but sometimes only mild pain/discomfort is present
• watering and photophobia
• gradual decrease in vision
  
  • Pain with eye movement
• Abnormal pupil reaction to light
• Tenderness to palpation of the eye

Question 8

Scleritis - management?

Answer 8

Patients with potentially sight threatening causes of red eye should be referred for same day assessment by an ophthalmologist

Management in secondary care:

• Consider an underlying systemic condition
• NSAIDS (topical / systemic)
• Steroids (topical / systemic)
• Immunosuppression appropriate to the underlying systemic condition (e.g. methotrexate in rheumatoid arthritis)

Question 9

What test can you do to differentiate between episcleritis and scleritis?

Answer 9

Phenylephrine drops

Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels

If the eye redness improves after phenylephrine a diagnosis of episcleritis can be made

Question 10

What happens in episcleritis and scleritis if you apply pressure on the sclera?

Answer 10

In episcleritis, the injected vessels are mobile when gentle pressure is applied on the sclera

In scleritis, vessels are deeper, hence do not move