See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/49713160

Episcleritis and scleritis

Article  in  Insight - the Journal of the American Society of Ophthalmic Registered Nurses · October 2010
Source: PubMed

CITATIONS READS
4 592

2 authors, including:

Bradley J Kirkwood
Flinders University
27 PUBLICATIONS   189 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Bradley J Kirkwood on 20 August 2014.

The user has requested enhancement of the downloaded file.

 Episcleritis and Scleritis
by Bradley J. Kirkwood, ma, bn, rn and Rodney A. Kirkwood, md, franzo
Bradley J. Kirkwood, MA, BN, RN
Ophthalmic Nurse Specialist
Professional Eye Centre, Mackay
Queensland, Australia
P.O. Box 10122
Mt. Pleasant, Queensland
Australia 4740
Bradkirkwood@bigpond.com
Rodney A. Kirkwood, MD, FRANZO
Disclosure: The authors have disclosed
that they do not have a conflicting rela-
tionship of a financial, professional, or
personal nature related to this activity.
Learning Objectives:
1. Describe two clinical features of
­episcleritis and scleritis.
2. Differentiate the etiology, onset and
therapeutic interventions for episcleritis
and scleritis.
Accreditation: This continuing education
activity is provided by ASORN.
ASORN is accredited as a provider of con-
tinuing nursing education by the Ameri-
can Nurses Credentialing Center’s COA.
Post-test: To take this examination for
continuing education credits, go to
www.actioned.org.
Summary
This article will briefly discuss episcleritis and scleritis as clinical entities. Both are
forms of ocular inflammation but have different clinical, therapeutic and prognos-
tic implications. Episcleritis is a self-limited disease, causing mild discomfort and
infrequently requiring therapeutic intervention. Scleritis is a painful, inflammatory
process, commonly associated with systemic disorders and requires systemic anti-in-
flammatory therapy. It is important to be able to distinguish between the two clinical
conditions, as prompt initiation of therapy for scleritis can be sight saving.
Introduction
Episcleritis and scleritis are distinct forms of ocular inflammation with different
clinical, therapeutic and prognostic implications. Episcleritis is a self-limited disease,
commonly idiopathic in nature, and therefore infrequently requires therapeutic
intervention.1 It involves the superficial aspect of the sclera, with symptoms usually
limited to mild discomfort. In direct comparison, scleritis is a painful, severe, destruc-
tive inflammatory process that poses a significant threat to vision.2 It is frequently
associated with systemic disorders and requires systemic anti-inflammatory therapy.2
Although both episcleritis and scleritis are relatively uncommon, it is important to
be able to distinguish between the two clinical conditions, as prompt initiation of
therapy for scleritis can be sight saving. This article will briefly present the related
anatomy of the sclera and then discuss the clinical and management variations for
episcleritis and scleritis.
Anatomy
The human sclera is the “white” of the eye and is a tough coat of connective tissue that
functions both to protect the intraocular contents and to maintain the shape of the
globe. The word sclera is derived from the Greek words sklera mannix, meaning hard
membrane.3 It accounts for approximately 90% of the outer coat of the eye and begins
at the limbus and terminates at the optic canal.2 The sclera is thickest posteriorly
(1.0 mm) and thinnest (0.3 mm) behind the insertion of the extraocular muscles.4
At the limbus, the sclera is 0.8 mm thick.4
For anatomical description, the sclera can be divided into three sections: the episclera,
the scleral stroma and the lamina fusca.4 The episclera is the outermost layer and is
comprised of loose connective tissue that lies immediately beneath Tenon’s capsule.
It has a rich blood supply from the anterior ciliary arteries which forms a plexus (net-
work). It has two layers: a superficial parietal layer and a deep visceral layer. These two
layers are loosely fused by fine connecting fibers. The superficial parietal layer is vas-
cularized by the episcleral capillary plexus, which has a uniquely straight and radially
oriented vessel appearance. The visceral layer, which is closely adherent to the sclera,
contains the deep episcleral capillary plexus. The freely anastomosing configuration
of this capillary plexus characterizes this layer. In addition, the episclera also acts as a
synovial membrane for smooth movement of the eye.
The scleral stroma consists of dense fibrous tissue and fine elastic fibers. Collagen
bundles of varying shapes and sizes are not uniformly orientated, giving it its opaque
5
 I n s i g h t The Journal of the American Society of Ophthalmic Registered Nurses, Inc. | October–December 2010 | Vol. XXXV, No. 4
Continuing Education (CE) Article

Episcleritis and Scleritis

Continued from page 5

appearance. This is in contrast to the transparency of the

cornea, where the collagen is more uniformly orientated, run-
ning parallel to the surface. Although the sclera is a relatively
avascular structure, it derives its nutrition from the overlying
episclera and underlying choroid blood supply. It also receives a
profuse sensory innervation. Small apertures in the sclera allow
for branches of the ciliary vessels and nerves to be transmitted
and provide an exit for the vortex veins. The inner layer of the
sclera is the lamina fusca. It blends with the uveal tract and has
grooves in which the ciliary nerves and vessels are housed.
Figure 1: Simple episcleritis with engorgement of the radially oriented
Episcleritis superficial episcleral vessels

Episcleritis is a relatively benign, self-limiting inflammatory

condition where the inflammation is primarily confined to the
superficial parietal layer. Clinically the condition is categorized
as either simple or nodular.5 The simple form demonstrates
vascular congestion of the episclera, which can be widespread or
sectorial (Figure 1). Nodular episcleritis has a well-demarcated,
elevated area of inflamed episcleral tissue and the nodule is
mobile (Figure 2). In both forms, the inflammation does not
involve the deep visceral layer of the episclera or the sclera.
The incidence of episcleritis is unclear, as it is self-limiting in
nature and many patients do not seek professional advice.6 It Figure 2: Nodular episcleritis
occurs most commonly between 20–50 years of age and has
been shown to have a slight female predilection.6 The major-
Visual acuity in episcleritis patients is typically unaffected.
ity of episcleritis is idiopathic in nature. However, a number of
Unilateral and bilateral cases can present and the injection
­patients have an associated systemic condition such as rheu-
of episcleritis occurs typically in the interpalpebral area. This
matoid arthritis, ulcerative colitis, gout, atopy, herpes zoster,
injection is typically fiery or brick red.8 Natural sunlight and an
rosacea, Wegener’s granulomatosis or polyarteritis nodosa.5
unmagnified view can be useful in distinguishing the redness
Stress has also been implicated.7
of episcleritis from the bluish-violet hue of scleritis.8 Although
Episcleritis generally has an acute onset, particularly in the ­engorged, the radially oriented vessels of the superficial epi-
simple form, and the most common patient complaint is ocular scleral capillary plexus maintain a normal architecture. To assist
redness. Less frequently, the patient may complain of a sensation in making a diagnosis, conjunctival and superficial vessels can
of heat, prickling, photophobia or ocular pain, and localized be blanched with 2.5%–10% phenylephrine or 1:1,000 epineph-
discomfort may occur. The nodular variety is usually more rine while the deep vessels are barely affected.2 Additionally,
uncomfortable than the simple variety. Inflammation typically slit-lamp examination with a red-free (green) filter accentuates
peaks 24 hours after the onset of symptoms.5 A slow improve- the visibility of blood vessels.
ment develops in 5 to 10 days, with complete resolution usually
Treatment of simple episcleritis is usually not required, as the
by 2 to 3 weeks.5 Recurrences can occur in decreasing frequency
patient is often asymptomatic. Treatment may be justified if the
for 3 to 6 years.5 Recurrent attacks of episcleritis in the same
condition is severe, persistent, recurrent or if nodular episcleri-
location may lead to an alteration of the superficial scleral
tis is present. Simple therapy such as cool compresses and cold
lamellae. If a patient continues to have recurrent attacks with no
artificial tears can provide a lubricating, soothing and vasocon-
noted systemic disease associations, a systemic evaluation may
stricting effect. Topical or oral nonsteroidal anti-inflammatory
be warranted. Fortunately, complications are uncommon from
drugs (NSAIDs) may be required if the simple therapy treat-
episcleritis and conditions such as mild anterior uveitis, mild
ment is unsuccessful. A short and rapid tapering regime of
corneal changes and corneal dellen may occur.5
topical corticosteroids may also be used for more recalcitrant

6
I n s i g h t The Journal of the American Society of Ophthalmic Registered Nurses, Inc. | October–December 2010 | Vol. XXXV, No. 4
Continuing Education (CE) Article

cases. The treatment of episcleritis should also be directed at any

underlying disease process.

Scleritis
Scleritis is a severe, potentially destructive disorder with an
entirely different prognosis from episcleritis. The incidence of
scleritis has been estimated to occur in between 0.08% and 4%
of patients1, is most common between 20–60 years of age and
more frequently affects females.6 In general, scleritis can be
­divided into two major categories: non-infectious and infec-
tious.9 The first, noninfectious scleritis, is most commonly
caused by immune-mediated disorders such as Wegener’s
Figure 3: Diffuse anterior scleritis
granulomatosis, rheumatoid arthritis and relapsing polychon-
dritis. Scleritis may be the initial presenting clinical sign of these
conditions. Up to 50% of patients with scleritis have evidence scleral tissue becomes thin and translucent. Some areas of ciliary
of an underlying systemic disease.2 The second group, infectious body or choroid may be covered only by conjunctiva.
scleritis, is most commonly caused by surgery or local extension
Necrotizing scleritis without inflammation, also termed
from adjacent ocular tissues. Scleritis is classified on the basis
scleromalacia perforans, is characterized by patients remain-
of clinical appearance and divided into anterior and posterior
ing largely asymptomatic. It is most common in women with
forms.8 Anterior scleritis is further divided into diffuse, nodu-
rheumatoid arthritis.1 Patients may notice a discoloration of
lar, necrotizing with inflammation and necrotizing without
the sclera or present with blurred vision because of astigmatism.
inflammation (scleromalacia perforans).8
Thinned and avascular areas of episclera and sclera with no sur-
Prompt diagnosis of scleritis is essential and differentiation from rounding inflammation can be noted on examination. Despite
the more benign episcleritis can often be made by a detailed his- pronounced thinning in some cases, perforation is rare without
tory, an external examination and a careful slit-lamp examina- scleral trauma or very high intraocular pressure.9
tion to determine which layers of the ocular wall are involved
Posterior scleritis represents 2% to 12% of scleritis cases and is
with the inflammation. Slit-lamp examination also reveals
defined as involvement of the sclera posterior to the insertion of
scleral edema, distortion and tortuosity of both superficial and
the rectus muscles.1 Posterior scleritis may occur in isolation or
deep vascular networks with loss of the normal radial pattern.
can be accompanied by anterior scleritis. Presenting symptoms
Avascular areas with blood vessel closure are indicative signs
can include extreme pain or loss of vision. In more advanced
of scleritis and do not occur in episcleritis. Such an appearance
cases, retinal or choroidal folds, macular edema and glaucoma
strongly suggests necrotizing scleritis. Most scleral disease is
may be noted.1 Diffuse and nodular forms can be delineated
bilateral and recurrent. Patients presenting with scleritis will
with the use of imaging studies such as B-scan ultrasonography
often complain of pain, severe enough to awaken them at night,
and magnetic resonance imaging.2
which may radiate to the forehead, brow or jaw. The pain tends
to be gradual in onset. A history of red eye(s), accompanied by Treatment of scleritis is aimed at reducing morbidity and
photophobia, blurred vision and tenderness to touch will often minimizing complications. Systemic anti-inflammatory and
accompany the ocular pain. The sclera often takes on a bluish- immunosuppressive medications are utilized, as topical therapy
violet color. Visual loss may be caused by keratitis, cataract, alone is ineffective. Initial therapy consists of oral NSAIDs
macular edema or uveitis.1 These complications are rarely pres- and/or oral corticosteroids. Immunosuppressive drugs such as
ent in episcleritis. methotrexate and cyclophosphamide may need to be added or
substituted if unresponsive to the initial therapy. Intravenous
Diffuse anterior scleritis is the most common presentation of
therapy corticosteroids and immunosuppressive drugs may be
scleritis and tends to be the least severe (Figure 3). It often has
required for urgent cases. Rarely, surgical treatment such as a
an insidious onset and may resemble diffuse episcleritis as over-
tectonic scleral graft can be used to preserve the globe.
lying episcleral injection is present. Nodular anterior scleritis
presents with a nodule that is firm, immobile and tender on Infections of the sclera are uncommon, accounting for approxi-
palpation. Necrotizing anterior scleritis with inflammation mately 5% to 15% of cases.10 Scleral infections may be classi-
is the most severe type of scleritis and is associated with the fied into two groups: exogenous and endogenous infections.9
greatest potential for visual loss. Avascular areas of sclera and The first, exogenous infections, are most common and include
conjunctiva, with surrounding scleral oedema and congestion, post-traumatic and post-surgical infections (Figure 4). These
are frequently seen. Uveal tissue may be seen as the overlying exogenous infections tend to be acute, suppurative and destruc-
tive. The second group, endogenous infections, is less common

7
 I n s i g h t The Journal of the American Society of Ophthalmic Registered Nurses, Inc. | October–December 2010 | Vol. XXXV, No. 4
Continuing Education (CE) Article

Episcleritis and Scleritis

Continued from page 7

and is associated with systemic infections such as syphilis and

tuberculosis. Symptoms of infectious scleritis include pain, red-
ness, tenderness to touch, blurred vision and purulent discharge.
Systemic treatment in association with topical antimicrobial
therapy is required. Effective treatment of infectious scleritis
requires culture or pathologic evidence of a causative organism.
The poor prognosis associated with infectious scleritis is attrib-
uted mainly to the minimal penetration of topical or intrave-
nous antibiotics into the nearly avascular sclera.

Conclusion
Episcleritis and scleritis are distinct clinical entities. Differentia-
tion between the two disorders can be made through a detailed
history, an external examination and a careful slit-lamp exami-
nation. Episcleritis is a relatively benign, self-limited disease,
infrequently requiring therapeutic intervention. Scleritis is a
painful, inflammatory process, requiring systemic anti-inflam-
matory therapy and frequently associated with systemic autoim-
mune disorders. A prompt diagnosis of scleritis and initiation of
therapy is essential to assist in minimizing ocular complications.
References
1. Soukiasian S. Episcleritis and Scleritis: Diagnosis and Therapy. Sem Ophthal-
mol 1996;11(1):79–92.
2. Okhravi N, Odufuwa B, McCluskey P, Lightman S. Scleritis. Surv Ophthal-
mol 2005;50(4):351–63.
3. Sainz de la Maza M, Foster C. Vol. 1, Chapter 23: Sclera. In: Tasman W,
Jaeger E, editors. Duane’s Ophthalmology on CD-ROM 2006 Edition.
Philadelphia: Lippincott, Williams and Wilkins; 2006.
4. Snell R, Lemp M. Clinical anatomy of the eye. 2nd ed. Malden: Blackwell
­Science; 1998; pp. 139–143.
Figure 4: Infectious necrotising scleritis following pterygium surgery
5. Pearlstein E. Chapter 118: Episcleritis. In: Krachmer J, Mannis M, Holland
E, editors. Cornea Text & Color Atlas CD-ROM: Mosby CD online;
1998.
6. Jones W. Chapter 28: Diseases of the sclera. In: Bartlett J, Jaanus S, editors.
Clinical ocular pharmacology. 4th ed. Woburn: Butterworth-Heine-
mann; 2001; pp. 701–713.
7. Margo C. Recurrent episcleritis and emotional stress. Arch Ophthalmol.
1984;102(6):821–24.
8. Watson P. Vol. 4, Chapter 26: Diseases of the sclera and episclera. In: Tas-
man W, Jaeger E, editors. Duane’s Ophthalmology on CD-ROM 2006
Edition. Philadelphia: Lippincott, Williams and Wilkins; 2006.
9. Schwam B, Raizman M. Chapter 119: Scleritis. In: Krachmer J, Mannis M,
Holland E, editors. Cornea Text & Color Atlas CD-ROM: Mosby CD
online; 1998.
10. Raizman M. Chapter 80: Microbial scleritis. In: Pepose J, Holland G,
­Wilhelmus K, editors. Ocular infection and immunity. St. Louis:
Mosby; 1996; p. 1081–7.

CE Tests for ASORN Insight Continuing Education Activities Have Moved Online! Take This Test Now!
Online Education and Assessment Site Launches
Eye care professionals now have a new online source for continuing education and training: ACTIONed®, (Assessment,
Certification, Training, an Interactive Online Network Education). The site is the collaborative effort of six organizations.
Together, the Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO®), the American Society of
Ophthalmic Registered Nurses (ASORN), the Association of Technical Personnel in Ophthalmology (ATPO), the Canadian
Society of Ophthalmic Medical Personnel (CSOMP), the Ophthalmic Photographer’s Society (OPS), and the American
Society of Association Executives (ASOA) teamed to produce a comprehensive online training resource for eye care
professionals. The result is an online educational partnership never seen before among ophthalmic organizations.
To take the test for this activity and earn continuing education credits, visit www.actioned.org to create a personal
profile and start your training and career development today.

View publication stats