Clinical characteristics and ocular complications of patients with scleritis in Japanese

Necrotizing Scleritis: A Review

Necrotizing scleritis is the most destructive and vision-threatening form of scleritis. Necrotizing scleritis can occur in systemic autoimmune disorders and systemic vasculitis, as well as following microbial infection. Rheumatoid arthritis and granulomatosis with polyangiitis remain the commonest identifiable systemic diseases associated with necrotising scleritis. Pseudomonas species is the most common organism causing infectious necrotizing scleritis, with surgery the most common risk factor. Necrotizing scleritis has the highest rates of complications and is more prone to secondary glaucoma and cataract than other phenotypes of scleritis. The differentiation between non-infectious and infectious necrotizing scleritis is not always easy but is critical in the management of necrotizing scleritis. Non-infectious necrotizing scleritis requires aggressive treatment with combination immunosuppressive therapy. Infectious scleritis is often recalcitrant and difficult to control, requiring long-term antimicrobial therapy and surgical debridement with drainage and patch grafting due to deep-seated infection and the avascularity of the sclera.

Pediatric Scleritis: An Update

Posterior idiopathic scleritis is the most common type of scleritis observed in childhood. Nevertheless, anterior and even necrotizing inflammatory scleritis may occur as well. Although less frequently than in the adult population, scleral inflammation can be associated with systemic disorders, which should be promptly recognized and treated to avoid both ocular and systemic complications. Hence, a multidisciplinary diagnostic work-up should be performed to rule out primarily infectious and autoimmune causes, such as viral and bacterial infections, anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis, pediatric sarcoidosis, Behçet's disease and HLA-B27-associated diseases. Treatment of scleritis should aim to control ocular inflammation, relieve symptoms and prevent relapses, to avoid complications, preserve visual acuity and improve the child's quality of life. It should be tailored to the patient, considering the type and severity of scleritis, the possible identification of an infectious cause or the presence of an associated rheumatologic condition.

Adalimumab plus Conventional Therapy versus Conventional Therapy in Refractory Non-Infectious Scleritis

Long-term systemic glucocorticoids and non-specific immunosuppressants remain the mainstay of treatment for refractory scleritis, and result in serious side-effects and repeated inflammation flares. To assess the efficacy and safety of additional adalimumab, patients diagnosed with refractory non-infectious scleritis were enrolled. They were assigned to the conventional-therapy (CT, using systemic glucocorticoids and other immunosuppressants) group or the adalimumab-plus-conventional-therapy (ACT) group according to the treatments they received. The primary outcome was time to achieve sustained remission, assessed by a reduction in modified McCluskey's scleritis scores. Other outcomes included changes in McCluskey's scores, scleritis flares, best-corrected visual acuity, and spared glucocorticoid dosage. Patients in the ACT group achieved faster remission than those in the CT group, as the median periods before remission were 4 months vs. 2.5 months (p = 0.016). Scleritis flares occurred in 11/11 eyes in the CT group and 5/12 eyes in the ACT group (p = 0.005). Successful glucocorticoid sparing was realized in both groups, but the ACT group made it faster. No severe adverse events were observed. Data suggest that adalimumab plus conventional therapy could shorten the time to remission, reduce disease flares, and accelerate glucocorticoid withdrawal compared with conventional therapy alone.

Patterns of Non-Infectious Scleritis across a Tertiary Eye Care Network Using the Indigenously Developed Electronic Medical Record System-eyeSmart

PURPOSE

To report the pattern of noninfectious scleritis across a tertiary eye-care network.

METHODS

A three-year retrospective review of patients diagnosed with noninfectious scleritis was performed. Data were retrieved using diagnostic terms assigned to scleritis through the in-house eyeSmart-electronic medical record system.

RESULTS

1103 patients, with a mean age of 44.33 ± 14.38 years and a median follow-up of 199.5 days (range 32-685) were enrolled. Unilateral disease was noted in 85%. Diffuse anterior scleritis (n = 542, 42.51%) and nodular scleritis (n = 482, 38.12%) were the commonest subtypes. Systemic immune disease association was present in 65 (5.89%). Treatment at onset was topical corticosteroids (n = 372, 36.54%) followed by oral non-steroidal anti-inflammatory drugs (n = 351, 34.45%), oral corticosteroids in 184 (19.04%), and immunomodulators in 32 patients (3.54%).

CONCLUSIONS

This study depicts the pattern of various noninfectious scleritis in a large cohort of patients. The present study helped to further customize the electronic medical records to minimize several data capture limitations.

Clinical patterns and risk factors in scleritis: a multicentric study in Colombia

PURPOSE

This study aims to describe the clinical characteristics of scleritis in a large cohort of Colombian patients and identify factors associated with the clinical presentation.

METHODS

Retrospective case series of patients with scleritis from 2015 to 2020. Clinical records were obtained from seven uveitis referral centers in Colombia. Patients with a diagnosis of episcleritis were excluded.

RESULTS

We evaluated 389 patients with scleritis (509 eyes). There was a female predominance (75.6%) with a mean age of 51 ± 15 years. Most cases were noninfectious (94.8%) and unilateral (69.2%). The most frequent type of inflammation was diffuse anterior scleritis (41.7%), followed by nodular scleritis (31.9%) and necrotizing scleritis (12.3%). Systemic autoimmune diseases were found in 41.3% of patients, the most common being rheumatoid arthritis (18.5%) and granulomatosis with polyangiitis (5.9%). Polyautoimmunity was found in 10.4% of those with a systemic autoimmune disease. The most frequent treatment was systemic steroids (50.9%), followed by systemic NSAIDs (32.4%). Steroid-sparing immunosuppression was required in 49.1% of patients. Systemic autoimmune diseases were more common in patients with necrotizing scleritis and those older than 40 years of age. Best-corrected visual acuity of 20/80 or worse at presentation was more common in necrotizing scleritis and subjects with associated uveitis, ocular hypertension, or who were over 40 years of age.

CONCLUSIONS

This is the first study in Colombia and the largest in Latin America describing the clinical characteristics and presentation patterns of scleritis. The most common presentation was in females, with unilateral, anterior diffuse noninfectious scleritis. Systemic autoimmune diseases and polyautoimmunity were frequent, as was the need for steroid-sparing immunosuppression. Age over 40 and necrotizing scleritis were associated with higher odds of having a systemic autoimmune disease and worse visual acuity at presentation.

Clinical Profile, Systemic Association, Treatment and Visual Outcome of Patients with Scleritis in an Eye Care Center in Mexico City

AIMS

To describe demographic and clinical characteristics as well as etiologies and visual outcomes of patients with scleritis.

METHODS

This is a descriptive, observational and retrospective study. We reviewed the electronic health records of patients with diagnosis of scleritis, who presented at the Institute of Ophthalmology Conde de Valenciana from January 2009 to December 2019.

RESULTS

The cohort consisted of 162 patients with mean follow-up of 33.7 months. Mean age of scleritis presentation was 53.8 years. The most common type of scleritis was anterior nodular in 67 patients (41.3%). Most cases were idiopathic (52.4%). Visual outcomes were worse in anterior necrotizing scleritis. The most used drugs were oral NSAIDs and corticosteroids.

CONCLUSION

The visual outcome in most patients is favorable, however it depends on scleritis type and etiology, with worse prognosis in anterior necrotizing scleritis forms and associated with autoimmune or systemic diseases.

Associations between Sjögren Syndrome, Sociodemographic Factors, Comorbid Conditions, and Scleritis in a Taiwanese Population-Based Study

This nationwide, population-based, retrospective, matched case–control study included 111,960 newly diagnosed patients with scleritis who were identified by the International Classification of Diseases, Ninth Revision, Clinical Modification code 379.0, selected from the Taiwan National Health Insurance Research Database. Demographic characteristics, Sjögren syndrome, and comorbid conditions within 1 year before the scleritis diagnosis were examined using univariate logistic regression analyses, and a paired t-test was used for continuous variables. Adjusted logistic regression was used to compare the prognosis odds ratio (OR) of the patients with scleritis with the controls. After adjustment for confounders, patients with Sjögren syndrome were remarkably more likely to have scleritis than the controls (OR = 33.53, 95% confidence interval (CI) = 27.43–40.97, p < 0.001). Other conditions found to have increased odds of scleritis included post ocular pterygium, glaucoma, and scleral surgery (OR  =  4.01, 95% CI  =  3.64–4.43; OR  =  3.16, 95% CI  =  2.24–4.47; OR  =  6.83, 95% CI  =  5.34–8.74, respectively); systemic infections, such as syphilis, tuberculosis, and a human herpes viral infection (OR  =  4.01, 95% CI  =  2.93–5.50; OR  =  2.24, 95% CI  =  1.94–2.58; OR  =  8.54, 95% CI  =  8.07–9.03, respectively); and systemic diseases, such as rheumatoid arthritis, granulomatous vasculitis, systemic lupus erythematosus, ankylosing spondylitis, and gout (OR  =  2.93, 95% CI  =  2.66–3.23; OR  =  7.37, 95% CI  =  3.91–13.88; OR  =  3.18, 95% CI  =  2.63–3.85; OR  =  5.57, 95% CI  =  4.99–6.22; OR  =  2.84, 95% CI  =  2.72–2.96, respectively). The results strongly support an association between Sjögren syndrome, post ocular surgery, systemic infection disease, systemic autoimmune disease, and scleritis.

Optical coherence tomography versus ophthalmic examination findings in the management of anterior scleritis: A prospective study

PURPOSE

The goal of this work was to analyze optical coherence tomography (OCT) findings compared to ophthalmic examination results in the management of anterior scleritis.

METHODS

We carried out a prospective study including patients presenting with anterior scleritis who underwent complete clinical examinations and OCT at baseline and at the final follow-up visit.

RESULTS

The mean age was 46years. The superior and temporal quadrants were clinically the most involved regions and showed the greatest thickness on the OCT images. Nodules were observed clinically in 6 patients, while OCT revealed them in 9 cases. OCT revealed 3 cases of sub-clinical necrosis. Separation of fibers, scleral edema, dilated vessels, fluid pockets and increased scleral thickness were the most common signs of the disease. Mean total scleral thickness and mean scleral-episcleral complex thickness were significantly improved after treatment (P=0.001 and P=0.00; respectively). Post-streptococcal syndrome (PSS) was diagnosed in 3 cases of non-necrotizing anterior scleritis. Necrotizing forms were low-grade and were associated with systemic diseases in 2 out of 3 patients. OCT signs persisted for a substantial time after resolution of clinical signs.

CONCLUSION

OCT helped to distinguish necrosis and scleral nodules in subclinical cases. Non-necrotizing forms of scleritis supported the diagnosis of PSS, while necrotizing forms suggested systemic diseases. Complete resolution of a scleral inflammation could be followed more objectively with OCT than by clinical examination.

Choroidal involvement in non-infectious posterior scleritis

Purpose

To provide a comprehensive overview of choroidal involvement in non-infectious posterior scleritis; including different imaging modalities and their clinical usefulness.

Methods

Narrative review.

Results

Posterior scleritis is an uncommon yet potentially sight-threatening inflammation of the sclera. During the disease process, inflammation can spread to the adjacent choroid, causing different manifestations of choroidal involvement: (1) increased choroidal thickness, (2) choroidal vasculitis, (3) presentation as a choroidal or subretinal mass in nodular posterior scleritis, and (4) choroidal folds, choroidal effusion and exudative retinal detachment.

Conclusions

Clinical characteristics and multimodal imaging can aid in diagnosing and monitoring disease progression and response to treatment in non-infectious posterior scleritis with choroidal involvement.

Factors affecting the resolution of acute non-infectious anterior scleritis

BACKGROUND/AIMS

Tumor necrosis factor alpha (TNF-⍺) inhibitors are increasingly being used to treat scleritis, however, their efficacy has not been compared to older treatments. Additionally, few studies have assessed differences in the course of scleritis among different patient groups. We identify demographic factors, comorbidities and treatments associated with the resolution of acute scleritis.

METHODS

The records of patients with non-infectious anterior scleritis who presented between 1 January 2013 and 1 January 2018 were retrospectively reviewed.

RESULTS

A total of 141 patients (169 eyes) with anterior scleritis were identified. 92.9% had diffuse anterior scleritis, 5.0% had nodular anterior scleritis and 2.1% had necrotising scleritis. Topical corticosteroids were used in 66.7% of patients, systemic non-steroidal anti-inflammatory drugs (NSAIDs) in 48.9% and systemic corticosteroids in 37.6%. Non-corticosteroid immunomodulatory therapies were required in 37.6% of patients. In a Cox proportionate hazards model, factors positively associated with the resolution of an episode of scleritis included NSAID use (HR=2.145; 95% CI 1.200 to 3.832), Hispanic race (HR=2.991; 95% CI 1.115 to 7.341) and lupus erythematous (HR=6.175; 95% CI 1.774 to 21.489). Bilateral scleritis was negatively associated with resolution (HR=0.437; 95% CI 0.196 to 0.972). TNF-⍺ inhibitors (HR=3.346; 95% CI 1.277-8.763), NSAID use (HR=2.558; 95% CI 1.383 to 4.729), lupus erythematosus (HR=5.251; 95% CI 1.478 to 18.659) and Hispanic race (HR=3.198; 95% CI 1.022 to 10.005) were significantly positively associated with steroid sparing resolution.

CONCLUSION

Patient characteristics including a lupus diagnosis and Hispanic race were associated with faster times to symptom resolution and steroid sparing resolution, as were treatments including systemic NSAIDs and TNF-⍺ inhibitors. Due to limitations in the available data, this analysis did not account for disease severity. Future prospective studies will further elucidate the relationship between these factors and patient outcomes.

Clinical profile of patients with anterior nodular scleritis in India

Purpose:

To report the clinical profile of a series of anterior nodular scleritis in Indian population.

Methods:

We conducted a retrospective review of medical records of 140 eyes of 123 consecutive patients with nodular scleritis who presented to a tertiary eye care institute between 2007 and 2018.

Results:

The mean age at presentation was 46.8 ± 13.1 years and 70.7% of the patients were female. Bilateral involvement was observed in 14% patients. The most common presenting symptom was redness (92.6%) and ocular pain (69.1%). Twenty-seven patients (22%) had some systemic association and rheumatoid arthritis (5%) was the most common autoimmune disease. Presumed ocular tuberculosis was diagnosed in 13% patients. Methotrexate was the most common immunosuppressive used in these patients and an additional immunosuppressive was required in 6.5% patients. Recurrence of inflammation was observed in 74.8% patients. Deterioration of vision noted in 2.8% eyes.

Conclusion:

Tuberculosis remains an important cause of nodular scleritis in India. Recurrence of scleritis is common in nodular scleritis and cases with non infectious nodular scleritis often require treatment with immune suppressives.

Nodular Posterior Scleritis Masquerading as a Subretinal Mass

This is the case report of a 50-year-old female with no systemic comorbidities who presented to the eye clinic with a 1-month history of right-sided eye pain and visual loss. Examination revealed no signs of inflammation in the right eye, with no proptosis or conjunctival injection. A relative afferent pupillary defect was present with no inflammatory cells in the vitreous. On fundoscopy, there was a swollen disc, a large superior creamy white subretinal mass associated with a shallow overlying retinal detachment. B-scan ultrasonography confirmed the presence of a subretinal mass. Hematological investigations revealed an elevated erythrocyte sedimentation rate. Infective and autoimmune markers were negative. A diagnosis was made of nodular posterior scleritis and the patient was treated with intravenous corticosteroids initially, and subsequently switched to oral corticosteroids. There was complete resolution of the mass with optic atrophy as a result. Posterior nodular scleritis is an extremely rare potentially vision-threatening ocular condition that requires multimodal investigations to diagnose and treat appropriately.

Current Approach for the Diagnosis and Management of Noninfective Scleritis

ABSTRACT

Scleritis is a rare, vision-threatening inflammation of the sclera that is often associated with life-threatening systemic illnesses. Rheumatoid arthritis remains the most common associated systemic rheumatic disease and the commonest systemic association of scleritis. Granulomatosis with polyangiitis is the most common cause of vasculitis-associated scleritis. The etiopathogenesis of scleritis remains unclear, but can be immune complex-mediated or due to a local delayed hypersensitivity reaction. Scleritis can involve either the anterior or posterior sclera, and has a wide spectrum of clinical presentations. Among the subtypes of scleritis, necrotizing scleritis has an increased risk of complications and is more commonly associated with anterior uveitis and peripheral ulcerative keratitis. Posterior scleritis is often not diagnosed or missed due to its subtle clinical signs and protean manifestations. Meticulous history taking, detailed ocular examination, and a targeted array of investigations with a multi-disciplinary approach to find any underlying systemic disease are crucial for the management of a case of scleritis. Corticosteroids remain the mainstay of short-term treatment of scleritis; mild to moderate scleral inflammation may respond well to treatment with nonsteroidal antiinflammatory drug or topical corticosteroid. Corticosteroid-sparing immunosuppressive therapies are useful in cases with an inadequate response or failure to provide long-term control of inflammation, and to prevent recurrence of scleritis. Biologic agents are increasingly used in the management of scleritis, not responding to the conventional therapies. This review provides an overview of the various subtypes of scleritis and its systemic associations and evaluates current trends in the diagnosis and management of noninfective scleritis.

Clinical characteristics and efficacy of methotrexate in Japanese patients with noninfectious scleritis

PURPOSE

To analyze the clinical characteristics and treatment of noninfectious scleritis in Japanese patients, focusing on the efficacy of methotrexate (MTX).

STUDY DESIGN

Retrospective.

PATIENTS AND METHODS

A retrospective study of patients with noninfectious scleritis treated at Hiroshima University from February 2016 to May 2020 was performed. The patients' clinical features, associated systemic diseases, treatments, and visual outcomes were studied. The efficacy of MTX was also analyzed.

RESULTS

The study comprised 57 patients (88 eyes) with noninfectious scleritis, of whom 31 had bilateral involvement and the majority had anterior diffuse scleritis (n = 45). The commonest ocular complication was anterior chamber cells (38.6%), followed by ocular hypertension (28.1%). Associated systemic diseases were observed in 24.6% of the patients. Systemic immunosuppressive treatment was required in 78.9% of the patients, and 45.6% of the patients needed corticosteroid-sparing immunosuppressive treatment. Treatment success was achieved in 88.2% of the patients. Decreased vision was observed in 9.8% of the patients with ≥ 3-month follow-up. Seventeen patients were treated with MTX; the median maximum dose was 16 mg/week (range 8-16 mg). The scleritis was well controlled in almost 80% of the patients treated with MTX and systemic corticosteroids ≤ 5 mg. MTX adverse effects occurred in 47.1% of the MTX-treated patients; they were either tolerable or improved with dose adjustment in most cases.

CONCLUSION

Our study suggests the significance of prompt initiation of corticosteroid-sparing immunosuppressive treatment in treating patients with refractory scleritis or those intolerant of systemic corticosteroids. Moreover, MTX may be used effectively and safely for the treatment of noninfectious scleritis in Japanese patients.

Current insights in the pathogenesis of scleritis

Scleritis is a sight-threatening inflammation characterized by severe pain and redness of the eye. It can cause blindness by severe complications like scleral and corneal necrosis, keratitis, and uveitis. The pathogenesis of scleritis is largely unknown due to a combination of the rarity of the disease, the little available human tissue-based research material, and the lack of animal models. The immune system is assumed to play a crucial role in the pathogenesis of scleritis. Multiple clues indicate probable antigenic stimuli in scleritis, and the involvement of matrix metalloproteinases in the destruction of scleral tissue. In this article we review the current insights into the pathogenesis of scleritis, and we suggest new hypotheses by implementing knowledge of systemic autoimmune disease pathogenesis. Understanding the pathogenesis of scleritis is crucial to improve the clinical management, as well as to find novel treatment modalities.

Clinical characteristics of scleritis patients with emphasized comparison of associated systemic diseases (anti-neutrophil cytoplasmic antibody-associated vasculitis and rheumatoid arthritis)

PURPOSE

We evaluated patient profiles, clinical features, associated systemic diseases, treatment modalities, and ocular complications in cases of scleritis and episcleritis.

STUDY DESIGN

Retrospective.

METHODS

Clinical data of 128 patients referred to the ophthalmology clinic at Jichi Medical University Hospital during the 4-year period from April 2011 to March 2015, and diagnosed with scleritis or episcleritis were examined. Gender, average onset age, unilateral or bilateral manifestation, classification type, associated systemic diseases, and treatments were retrospectively investigated.

RESULTS

The cohort consisted of 57 men and 71 women. Average onset age was 54.3 ± 17.4 years. Diffuse anterior scleritis was the most common type. It was noted in 43 (32.8%) patients, followed by episcleritis in 35 (27.3%), nodular anterior scleritis in 23 (18.0%), necrotizing anterior scleritis in 22 (17.2%), and posterior scleritis in 6 (4.7%). Eighteen (81.8%) of 22 patients with necrotizing anterior scleritis required some type of systemic medication, including corticosteroid, cyclophosphamide, cyclosporine, azathioprine, methotrexate, or rituximab administration. Forty (31.3%) had associated systemic diseases, which included 10 with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis and 8 with rheumatoid arthritis (RA). Patients with ANCA-associated vasculitis had a tendency to develop scleritis first and had significantly worse visual prognoses compared to those with RA.

CONCLUSIONS

Approximately 30% of the patients with scleritis and episcleritis had complications involving systemic diseases, including ten patients with ANCA-associated vasculitis and 8 with RA. ANCA-associated vasculitis was more often diagnosed after scleritis and patients suffered poorer visual prognoses than those with RA.