Introduction
Episcleritis refers to inflammation of the episclera (a thin layer of tissue overlying the sclera). The sclera is the front, white part of the eye which is covered by the conjunctiva. The episclera lies between the conjunctiva and the sclera. The blood vessels in the episclera can enlarge causing redness in the eye. Episcleritis also comes with moderate pain, irritation and tenderness. Scleritis refers to inflammation of the sclera. It is a tough, fibrous tissue that forms a protective outer layer of the eye. It makes up 83% of the eye’s outer surface.
Episcleritis is the more common of the two. However, scleritis is more serious because the inflamed vessels are more rooted in the eye. Autoimmune diseases are said to cause almost half of all scleritis cases.
Sub-Types
- Episcleritis
(i) Nodular episcleritis - Individuals have an associated systemic disease. It is painful.
(ii) Simple episcleritis - It is more common and recurrent.
- Scleritis
(i) Anterior scleritis which affects the front area of the eye. It is further divided into:
- Diffuse scleritis - Portrays extensive redness and swelling in the entire area of the front of the sclera. It is very common and can be treated
- Nodular scleritis - Nodules on the surface of the eye
- Necrotizing scleritis - The most dangerous and can obliterate scleral tissues leading to loss of the eye. An individual will experience extreme pain and tenderness.
(ii) Posterior scleritis - It is scarce and affects the back part of the eye. It has no relationship with any systemic disorder. It can develop on its own or from anterior scleritis. It is also painful and feels tender to the touch.
Causes and Risk Factors
Episcleritis and scleritis are associated with autoimmune diseases. These diseases include rheumatoid arthritis, lupus, rosacea and Crohn’s disease. Others include inflammatory bowel syndrome, gout, Hodgkin’s lymphoma, among others.
Other causes may include foreign bodies in the eye and chemical injuries. Bacteria and other infections can cause scleritis. Episcleritis is rarely caused by infections.
Medications like topiramate can also cause the two diseases.
Sometimes the cause is unknown for both.
Episcleritis affects individuals between the ages of 20 and 50.
Scleritis occurs in people between the age of 30 and 60. It is rare in children.
Most studies show that females are more affected than males.
Signs & Symptoms
The symptoms for episcleritis may include:
- Redness in the eye
- Photophobia
- discomfort
- Tenderness in the eye
- Watery eyes
- Pain
The symptoms of scleritis may include:
- Inflammation and redness of the white part of the eye
- Severe pain in the eye, which extends to the face, jaw and head
- Blurred vision
- Watery eyes
- Extreme sensitivity to light
- Partial or complete loss of vision
There is a rare type of scleritis that does not cause pain or redness.
Diagnosis
The eye professional will do a complete eye examination and take the individual’s history.
He/she will use a slit lamp to diagnose either disease. A slit lamp is a device that shines light into the eye. To distinguish between episcleritis and scleritis, phenylephrine 2.5% drops will be used. If the redness in the eye improves after administration of phenylephrine, episcleritis diagnosis can be made. Another way to distinguish the two is to conduct the examination only using daylight. This is because the natural color of the sclera is not distorted. In episcleritis, the eye is pink or red while in scleritis, the eye has a deep-bluish or violet tinge.
For a recurrent episcleritis case without autoimmune indication, a laboratory test is required. The test is done according to the individual’s history, examination and review of systems.
The professional may request for a blood test, magnetic resonance imaging (MRI) or other tests for scleritis.
Treatment
Treatment of episcleritis and scleritis is aimed at reducing inflammation and pain. Further, treatment of scleritis may be directed towards preventing loss of vision.
Medical Treatment
Episcleritis can go away without treatment in a couple of weeks. However, it can be treated using corticosteroid eye drops or oral nonsteroidal anti-inflammatory drugs. The medication relieves pain and is useful in chronic/recurrent cases.
Scleritis is a serious disease that needs immediate attention. This is because of the risk of losing vision. Corticosteroid pills and non steroidal anti-inflammatory drugs can help reduce inflammation and pain. Antibiotics and eye solutions can also be used.
Certain anticancer drugs (immunosuppressants) may be used.
In situations where other disorders cause scleritis, treatment of these disorders is necessary. The therapy will control sclerosis symptoms.
Surgical Treatment
In more severe cases of scleritis, surgery is required to repair sclera tissue. This action may prevent loss of vision.
Home Care
In more severe cases of scleritis, surgery is required to repair sclera tissue. This action may prevent loss of vision.
Prognosis/Long-term outlook
Episcleritis should heal in 2-3 weeks unless it is associated with systemic diseases. Steroid use for episcleritis can result in glaucoma and cataract leading to declining vision. There is the risk of a recurrence in episcleritis. In rare cases, scleritis can develop from episcleritis.
Patients with scleritis will need long-term management. They will need regular visits to the doctor. They may also require long-term oral steroids and immunosuppressive drug therapy. Scleritis is likely to recur after treatment. There may also arise side effects from long-term corticosteroid therapy. If scleritis is not treated, it can lead to perforation of the eyeball and loss of vision.
Prevention/Follow Up
In most cases, episcleritis and scleritis cannot be prevented. However, people with autoimmune diseases may need a regular check-up with an eye doctor.
