Eye Pain in a Woman With Multiple Health Conditions

Byung Josh Kim, OD; Case Series Editor: Jean Marie Pagani, OD


March 24, 2014


Episcleritis is an acute, usually self-limited, benign inflammation of the loose, vascular episclera lying beneath the Tenon capsule and superficial to the sclera.[1] Episcleritis is classified as simple (80%) or nodular (20%). It is often sectoral but can have a diffuse presentation of subconjunctival and conjunctival injection.

The redness of simple episcleritis may be intense, varying from a fiery-red or a brick-red discoloration to a mild red flush, but it does not have the bluish tinge that is seen in scleritis. The episcleral vessels are engorged but retain their normal radial position and architecture. Nodular episcleritis is localized to one part of the globe, forming a nodule and some surrounding congestion.[2]

The signs and symptoms can vary, depending on the severity of the condition. Patients often will have a red, painful eye. Patients describe mild discomfort that can radiate to the forehead. It is usually unilateral but can be in both eyes. You may see chemosis, episcleral nodules, and anterior chamber cells and flare.[3] Patients rarely describe any discharge.

Because of the variation of the signs and symptoms, differentiating between episcleritis and scleritis can be difficult. The distinction between the two are important because the treatment course will vary.[1]

The blood vessels of the episclera are not easily visible in the uninflamed eye, but as soon as the eye becomes congested, 3 separate vascular plexuses become readily visible. The most superficial plexus is the bulbar conjunctival plexus. The arteries are supplied by the anterior ciliary arteries at the limbus, and the palpebral branches of the ophthalmic and lacrimal arteries. They typically will look bright red when inflamed. The episcleral plexus lies superficial to the episclera at a depth of one fourth to one third of the distance between the surface of the conjunctiva and sclera and is supplied by the ciliary arteries. The scleral plexus consists of a crisscross of vessels lying within the visceral layer of the Tenon capsule, close to the sclera.[4]

Careful examination will help determine initially whether the patient presents with episcleritis or scleritis. In episcleritis, no involvement of the sclera is noted.

Ocular complications, such as peripheral corneal involvement, uveitis, and glaucoma, can also be encountered with episcleritis. It is also important to look for concurrent eye disease that can be associated with episcleritis, such as ocular rosacea, keratoconjunctivitis sicca, and atopic keratoconjunctivitis.[1]

In most cases, episcleritis is an idiopathic finding. There have been links to associated systemic disorders, most commonly atopy, inflammatory bowel disease, systemic lupus erythematosus, and rheumatoid arthritis. Other diseases associated with episcleritis include herpes zoster, tuberculosis, and syphilis.[1] Exacerbations of ocular complaints in episcleritis are often associated with increased activity of the systemic disease.[5]

Scleritis and episcleritis both occur more commonly in patients with rheumatoid arthritis than in the general population.[6] Scleritis is a more significant disease of the sclera and has been shown to have a higher association with systemic disease.


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