Scleritis / Episcleritis

Written 16th July 2020 - Last Update 23rd July 2026

Scleritis / Episcleritis

Both cause a red eye without discharge, but scleritis is a severe, vision-threatening emergency while episcleritis is benign and self-limiting. Distinguishing them matters.

Scleritis

Severe, painful, vision-threatening inflammation of the sclera and deep episclera.

Associated systemic conditions: rheumatoid arthritis, herpes zoster, sarcoidosis, tuberculosis — and other systemic vasculitides.

History: red eye that is more violaceous (blue-red/purple) than episcleritis or conjunctivitis; deep, boring pain severe enough to interfere with sleep; ± photophobia and lacrimation.

Examination:

Redness may be segmental or involve the whole globe; palpebral conjunctiva is normal
Lacrimation without discharge (distinguishes it from conjunctivitis)
A raised nodule (nodular scleritis) or area of necrosis (necrotising scleritis) may be seen
The globe is tender to palpation

Nodular scleritis — hyperaemic, painful, oedematous, raised nodule

Necrotising scleritis — conjunctival ulceration with scleral necrosis; the blue-grey area is exposed choroid where sclera has thinned/lost

Scleritis — further example

Investigations: clinical diagnosis, but requires slit lamp examination.

Management:

Urgent referral — ophthalmology review within 24 hours
NSAIDs for mild cases (rarely sufficient alone)
Systemic steroids: prednisolone 1–2 mg/kg for 7 days then taper
Immunosuppressants for unresponsive cases
Refer for investigation of an underlying rheumatological condition — commonly present

Prognosis: significant risk to vision. Necrotising scleritis can progress to globe perforation, needing surgical repair or enucleation. 14% lose significant visual acuity at 1 year, 30% at 3 years. Necrotising scleritis carries a 50% 10-year mortality, largely from myocardial infarction related to the underlying systemic vasculitis.

Episcleritis

Recurring, self-limiting inflammation of the episclera (the thin vascular membrane between conjunctiva and sclera) that does not threaten vision.

Demographics: young adults, women > men.

History: localised redness, lacrimation, usually mild irritation. Distinguished from scleritis by the absence of photophobia/severe pain, and from conjunctivitis by the absence of discharge.

Examination: segmental hyperaemia, less violaceous than scleritis; no palpebral conjunctival involvement.

Episcleritis — segmental hyperaemia (lateral aspect here) mimicking conjunctivitis but with much less tearing and no discharge, and without the full bulbar+palpebral involvement seen in conjunctivitis

Investigations: clinical diagnosis with slit lamp examination.

Management: topical corticosteroid eye drops, ideally in consultation with ophthalmology.