Scleritis Therapy

Subconjunctival dexamethasone implant (Ozurdex®) in the management of refractory Non-Infectious anterior scleritis

OBJECTIVE

To report a case series of non-infectious anterior scleritis resistant to multiple lines of conventional therapies which were eventually successfully treated with off-label subconjunctival dexamethasone implant (Ozurdex®) injection (SDI).

METHODS

A retrospective case series of 4 patients (6 eyes).

RESULTS

In the index case series, the patients had a mean age of 57.2 years (range 36 to 82 years, SD 19.2 years) with 50% being female. Two patients had underlying autoimmune diseases: rheumatoid arthritis (n = 1), and granulomatosis with polyangiitis (GPA) (n = 1). The other patients were diagnosed with idiopathic anterior scleritis after extensive systemic investigations (n = 2). The mean follow-up duration and the mean number of concomitant therapies prior to SDI was 27 (SD 17.7) months and 2 (SD 0.81), respectively. In all patients, symptom resolution and significant improvement in disease activity were achieved after SDI, persisting for an extended period following the resorption of the implant. No scleral melt, infection or ocular hypertension were noted following SDI.

CONCLUSION

SDI may be a safe and effective therapeutic option for resistant non-infectious anterior scleritis.

Association of IL-23/IL-17 Pathway-Related Gene Polymorphisms with Idiopathic Scleritis in Chinese Han Population

PURPOSE

To examine the relationship between IL-23/IL-17 pathway gene polymorphisms and scleritis susceptibility in the Chinese Han population.

METHODS

We assessed IL-23/IL-17 pathway-related SNPs in 898 scleritis cases and 1,573 controls, employing stratified analysis to evaluate subtype-specific impacts and a discovery-validation cohort strategy to ensure genetic association reliability.

RESULTS

IL-23 R/rs10789229 TC genotype and C allele, and the IL-21/rs2221903 TT genotype and T allele were more frequent in scleritis patients (Pc = 2.07 × 10-3-2.77 × 10-6, OR = 1.497-2.327, 95% CI = 1.216-3.219), particularly anterior scleritis (Pc = 3.88 × 10-3-2.95 × 10-6, OR = 1.507-2.378, 95% CI = 1.209-3.321). The IL-23 R/rs10789229 TT genotype and T allele, and the IL-21/rs2221903 TC genotype and C allele were found less common among scleritis patients overall (Pc = 2.07 × 10-3-4.18 × 10-6, OR = 0.436-0.668, 95% CI = 0.316-0.822) and in the anterior scleritis subgroups (Pc = 3.88 × 10-3-4.43 × 10-6, OR = 0.427-0.664, 95% CI = 0.306-0.827). The analysis of haplotypes showed a noteworthy surge of IL-23 R CCCG haplotype in both scleritis patients in general (Pc = 1.91 × 10-4) and those with anterior scleritis (Pc = 1.15 × 10-4). Conversely, the frequency of the IL-17A GAA haplotype was significantly lower among scleritis patients overall (Pc = 4.17 × 10-12) and in the anterior or posterior scleritis subgroups (Pc = 7.41 × 10-11; Pc = 0.021). Only the IL-23 R/rs10789229 variant demonstrated consistent replication in the validation cohort.

CONCLUSIONS

The findings suggest that specific polymorphisms of IL-23/IL-17 pathway-related genes could confer risk to the development of scleritis in the Chinese Han population. Patients with varying subtypes of scleritis exhibit somewhat similar genetic profiles.

Clinical Course and Outcomes of Autoimmune Versus Non-Autoimmune Surgically Induced Scleral Necrosis: A Multicentric Comparative Study

BACKGROUND

To analyze the clinical course and outcomes of autoimmune vs. non-autoimmune surgically induced scleral necrosis (SISN).

METHODS

Multicentric, retrospective, comparative cohort study. Eighty-two eyes of 70 patients with SISN were classified according to pathogenic mechanism into autoimmune vs. non-autoimmune. Main outcome measures included necrosis onset, type of surgery, associated systemic disease, visual acuity, and treatment were analysed in patients followed for ≥ 6 months.

RESULTS

Forty-six (65.7%) patients were women, and the median age was 66 (range: 24-90) years. Most patients (82.9%) had unilateral disease. The median time between surgery and SISN onset was 58 (1-480) months. Thirty-one (37.8%) eyes were classified as autoimmune, and 51 (62.2%) as non-autoimmune SISN. Autoimmune SISN was associated with a shorter time between the surgical procedure and SISN onset than non-autoimmune cases (median of 26 vs. 60 months, p = 0.024). Also, autoimmune SISN was associated with cataract extraction (93.5% vs. 25.5%, p < 0.001), severe scleral inflammation (58.1% vs. 17.6%, p < 0.001), and higher incidence of ocular complications (67.7% vs. 33.3%, p = 0.002) than non-autoimmune cases. Remission was achieved with medical management alone in 44 (86.3%) eyes from the non-autoimmune and in 27 (87.1%) from the autoimmune group (p = 0.916). Surgical management was required in 11 (13.4%) eyes, including two requiring enucleations due to scleral perforation and phthisis bulbi.

CONCLUSIONS

Eyes with autoimmune SISN had a higher rate of cataract surgery, severe scleral inflammation, and ocular complications. Early SISN diagnosis and appropriate management, based on clinical features and pathogenic mechanisms, are critical to avoid sight-threatening complications.

Morphometric Assessment of Sclera and Ciliary Body in Patients with Noninfectious Anterior Scleritis: A Quantitative Study Using Ultrasound Biomicroscopy

BACKGROUND

At present, the severity and grade of anterior scleritis are judged mainly based on the area and location of involvement, whether there is necrosis, etc. Quantitative measurement of sclera and surrounding tissues will help to accurately assess the severity of scleritis and provide quantitative indicators for the choice of treatment.

METHODS

We retrospectively analyzed the thickness of sclera and ciliary bodies detected by ultrasound biological microscopy (UBM) in noninfectious anterior scleritis patients who subsequently were treated with topical or systemic treatment, and visited our hospital from March 2014 to March 2021. Age- and sex-matched normal individuals were used as controls.

RESULTS

A total of 185 patients (50 males and 135 females) with noninfectious anterior scleritis and 84 (31 males and 53 females) controls were included. In patients with noninfectious scleritis, the thickness of sclera and the ciliary body were significantly greater than those in the control group (p < 0.05). Before treatment, the thickness of sclera and the ciliary body in systemic treatment group was significantly higher than that in topical treatment group (p < 0.05). After treatment, both thicknesses of sclera and the ciliary body decreased significantly (p < 0.05). The ratio of ciliary body thickness from the site of inflammation to the normal position was significantly higher in the systemic treatment group than in the topical treatment group.

CONCLUSIONS

UBM quantitatively shows a decrease in AST/CBT in patients with anterior scleritis after treatment. The ratio of ciliary body thickness at the site of information to that at the normal position may be a reference for the choice of treatment.

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.

Therapeutic Outcomes of Non-Infectious Scleritis Treated with Tumor Necrosis Factor-Alpha Inhibitors

PURPOSE

We determine the efficacy of tumor necrosis factor-α (TNF) inhibitors in establishing scleritis quiescence.

METHODS

We conducted a multicenter retrospective chart review of patients with non-infectious scleritis treated with a TNF inhibitor for at least 6 months. The primary endpoint was scleritis quiescence at 6 months. Secondary endpoints included scleritis quiescence at 12 months, TNF inhibitor effects on concurrent doses of systemic corticosteroids and visual acuity outcomes at 6 and 12 months.

RESULTS

At 6 months, 82.2% (37/45) of subjects obtained scleritis quiescence with TNF inhibition. At 12 months, 76.2% (32/42) of subjects remained quiescent. Baseline daily corticosteroid use (21.5 ± 21.6 mg) decreased to 5.4 ± 8.3 mg by 6 months (p < 0.0001) and 2.8 ± 6.1 mg by 12 months (p < 0.001). There was no significant difference between the baseline and 6-month BCVA (p = 0.52).

CONCLUSIONS

TNF inhibitors are an effective scleritis therapy with significant systemic corticosteroid sparing effect.

Management of Scleritis in Older Adults

Scleritis, an inflammatory disease of the eye affecting scleral tissue, presents unique challenges in the older adult population. Unlike their younger counterparts, older individuals manifest a distinct spectrum of the disease with different underlying etiologies, co-morbidities, altered immune function, and an increased risk of systemic side effects from medication choices. Addressing these complexities necessitates a comprehensive and multidisciplinary approach. Treatment of choice will depend on any underlying cause but generally involves non-steroidal anti-inflammatory drugs, systemic or local corticosteroids, and potentially disease-modifying anti-rheumatic drugs. Utilization of these therapeutic agents in older adults warrants careful consideration because of their potential side-effect profiles. This article critically examines the specific concerns for the use of these drugs in older patients and reviews the existing literature on their use in this specific cohort.

Intravenous cyclophosphamide therapy for patients with severe ocular inflammatory diseases who failed other immunomodulatory therapies

BACKGROUND

Ocular inflammatory diseases, including scleritis and uveitis, have been widely treated with immunomodulatory therapies (IMTs) as a steroid-sparing approach. Such strategy includes conventional therapies (antimetabolites, alkylating agents, and calcineurin inhibitors) as well as biologic agents like adalimumab, infliximab, rituximab, and tocilizumab. Cyclophosphamide (CP) is an alkylating agent and mainly inhibits the functioning of both T and B cells. Though known to have potential adverse events, including bone marrow suppression, hemorrhagic cystitis, and sterility, CP has been shown to be efficacious, especially in recalcitrant cases and when used intravenous (IV) for a limited period.

MAIN FINDINGS

We conducted a retrospective case-series to assess the safety and efficacy of CP therapy for patients with severe ocular inflammatory diseases who failed other IMTs. Medical records of 1295 patients who presented to the Uveitis Clinic at the Byers Eye Institute at Stanford between 2017 and 2022 were reviewed. Seven patients (10 eyes) who received CP therapy for ocular inflammatory diseases with at least one year of follow-up were included. The mean age of the patients (4 males, 3 females) was 61.6 ± 14.9 (43.0-89.0) years. Clinical diagnoses included necrotizing scleritis (5 eyes), peripheral ulcerative keratitis (2 eyes), orbital pseudotumor (1 eye), HLA-B27 associated panuveitis and retinal vasculitis (2 eyes). Ocular disease was idiopathic in 3 patients, and was associated with rheumatoid arthritis, IgG-4 sclerosing disease, dermatomyositis, and ankylosing spondylitis in 1 patient each. All the patients had history of previous IMT use including methotrexate (5), mycophenolate mofetil (3), azathioprine (1), tacrolimus (1), adalimumab (2), infliximab (4), and rituximab (1). The mean follow-up time was 34.4 ± 11.0 (13-45) months, and mean duration of CP therapy was 11.9 ± 8.8 (5-28) months. Remission was achieved in 5 patients (71.4%). Four patients (57.1%) experienced transient leukopenia (white blood cell count < 4000/mL).

SHORT CONCLUSION

CP therapy can be considered a potentially effective and relatively safe therapeutic option for patients with severe ocular inflammatory diseases who failed other IMTs including biologics (TNFa and CD20 inhibitors).

ANCA-associated scleritis: impact of ANCA on presentation, response to therapy and outcome

OBJECTIVES

To describe the characteristics, treatment and outcome of isolated ANCA-associated scleritis at diagnosis compared with idiopathic scleritis with negative ANCA tests.

METHODS

This retrospective multicentre case-control study was performed within the French Vasculitis Study Group (FVSG) network and in three French tertiary ophthalmologic centres. Data from patients with scleritis without any systemic manifestation and with positive ANCA results were compared with those of a control group of patients with idiopathic scleritis with negative ANCA tests.

RESULTS

A total of 120 patients, including 38 patients with ANCA-associated scleritis and 82 control patients, diagnosed between January 2007 and April 2022 were included. The median follow-up was 28 months (IQR 10-60). The median age at diagnosis was 48 years (IQR 33-60) and 75% were females. Scleromalacia was more frequent in ANCA-positive patients (P = 0.027) and 54% had associated ophthalmologic manifestations, without significant differences. ANCA-associated scleritis more frequently required systemic medications, including glucocorticoids (76% vs 34%; P < 0.001), and rituximab (P = 0.03) and had a lower remission rate after the first- and second-line treatment. Systemic ANCA-associated vasculitis (AAV) occurred in 30.7% of patients with PR3- or MPO-ANCA, after a median interval of 30 months (IQR 16.3-44). Increased CRP >5 mg/l at diagnosis was the only significant risk factor of progression to systemic AAV [adjusted hazard ratio 5.85 (95% CI 1.10, 31.01), P = 0.038].

CONCLUSION

Isolated ANCA-associated scleritis is mostly anterior scleritis with a higher risk of scleromalacia than ANCA-negative idiopathic scleritis and is more often difficult to treat. One-third of patients with PR3- or MPO-ANCA scleritis progressed to systemic AAV.

Potential Biomarkers for Noninfectious Scleritis Identified by Serum and Tear Fluid Proteomics

Purpose

Scleritis is an extremely painful and potentially blinding inflammation of the sclera with unknown pathogenesis and unpredictable course. To gain insight in its disease process and identify biomarker candidates, we performed extensive proteomics in serum and tear fluid.

Design

Prospective multicenter cohort study.

Participants

A total of 121 patients with noninfectious scleritis (of which 39 active cases), 30 healthy controls, and 23 disease controls (uveitis and rheumatoid arthritis) were enrolled in the Netherlands from 2020 to 2022.

Methods

Serum, tear fluid of both eyes, and clinical data were gathered. The level of 368 inflammatory proteins was measured using proximity extension assays. Results were validated in an independent cohort of 15 patients with scleritis, and using addressable laser bead immunoassay, or enzyme-linked immunoassays. In addition, we studied an extended panel of matrix metalloproteinases in tear fluid of necrotizing scleritis with addressable laser bead immunoassay.

Main Outcome Measures

Statistically significant differences in the level of inflammatory proteins between patients with scleritis and control groups.

Results

Proteomics revealed 18 significantly upregulated or downregulated serum proteins in active scleritis cases compared with all control groups in both the discovery cohort and the validation cohort. The most upregulated protein was nuclear migration protein nudC (NudC; P = 0.0032), a protein involved in neurogenesis. The other significant hits included proteins involved in T-cell activation, apoptosis, epithelial barrier maintenance, and angiogenesis. Our tear fluid analysis showed matrix metalloproteinase 9 (MMP9) to be upregulated in the tear fluid of patients with scleral necrosis.

Conclusions

The results of our proteomics analysis suggest a role for neurogenesis, T-cell activation, disruption of epithelial barrier, and angiogenesis in the pathogenesis of scleritis, and highlight MMP9 and NudC as biomarkers with potential clinical relevance.

Funding Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

Presumed tuberculosis-related scleritis

AIMS

To evaluate the clinical characteristics and therapeutic outcome of patients with recurrent scleritis of unknown demonstrable aetiology and positive QuantiFERON-TB Gold In-Tube test (QFT).

METHODS

Retrospective chart review of the demographic, clinical, laboratory and therapeutic outcome data of 15 patients. Clinical characteristics as well as remission rate after standard antituberculous therapy (ATT) were assessed.

RESULTS

There were 9 men and 6 women with a mean age of 48.9 years (range, 32-73). Scleritis was diffuse in 10 patients (66.6%) and nodular in 5 patients (33.3%), 1 of them with concomitant posterior scleritis. It was bilateral in 7 patients (46.6%) and recurrent in all of them. Scleritis appeared after prior uveitis (10 patients, 66.6%) and/or with concomitant uveitis (5 patients, 33.3%) or peripheral keratitis (5 patients, 33.3%). Previous ocular surgery was found in 7 patients (46.6%). Previous extraocular tuberculosis (TB) infection or previous TB contact was detected in 11 patients (73.3%). No radiologic findings of active extraocular TB were detected. ATT was used in 15 patients, sometimes with the addition of systemic corticosteroids (5 patients) and methotrexate (1 patient); 14 patients achieved complete remission (93.3%).

CONCLUSION

Presumed TB-related scleritis may appear in recurrent scleritis of unknown origin and positive QFT. It may occur after prior uveitis and/or concomitantly with uveitis or peripheral keratitis, and it may be triggered by previous ocular surgery. No patients had evidence of concurrent active extraocular infection, although many had previous TB infection or TB contact. ATT was effective, sometimes with the addition of systemic corticosteroids and methotrexate.

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.

[Colchicine and non-severe ocular inflammation excluding Behcet's disease: 16 cases and literature review]

INTRODUCTION

Colchicine is a narrow therapeutic margin drug that does not have the adverse effects of corticosteroids and immunosuppressants. Its use in non-severe ocular inflammatory disease excluding Behcet's disease has not been studied.

METHODS

We included patients seen in the internal medicine department of Dijon University Hospital consecutively between September 2020 and September 2021 if they had received colchicine during their pathology. Patients with suspected Behçet's disease were excluded. Treatment efficacy was studied in patients with at least one year of disease progression who had received more than one year of colchicine. Successful treatment was defined as a 50 % reduction in the number of annual relapses on colchicine.

RESULTS

Sixteen patients were included (9 women and 7 men). They had recurrent anterior uveitis (n=10), recurrent scleritis (n=5) and intermediate uveitis. Opthalmological involvement was neither severe nor complicated. All patients combined, the annual relapse ratio (ARR) decreased from 1.8 (0.8-3.5) to 0.3 (0-1.6), (P=0.06). Colchicine was considered effective in three of 10 analyzable patients. In only one patient, treatment was stopped for adverse effects after six weeks.

CONCLUSION

In view of the interesting benefit-risk ratio of colchicine, it seems appropriate to focus on this molecule in non-granulomatous anterior uveitis and non-severe recurrent scleritis.

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.

Management of noninfectious scleritis

Scleritis is a manifestation of inflammatory eye disease that involves the sclera. It can be divided into multiple subtypes, including diffuse anterior, nodular anterior, necrotizing, and posterior scleritis. In many cases, scleritis is restricted to the eye; however, it can occur in the context of systemic illness, particularly autoimmune and infectious conditions. Patients with autoimmune conditions, such as rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematosus, and polyangiitis with granulomatosis, may develop scleritis flares that may require topical and systemic therapy. Initial therapy typically involves oral nonsteroidal anti-inflammatory drugs (NSAIDs); however, it is important to address the underlying condition, particularly if systemic. Other treatment regimens typically involve either local or systemic steroids or the use of immunomodulatory agents, which have a wide range of efficacy and documented use in the literature. There is a myriad of immunomodulatory agents used in the treatment of scleritis including antimetabolites, calcineurin inhibitors, biologics, and alkylating agents. In this review, we highlight the various subtypes of noninfectious scleritis and explore each of the mainstay agents used in the management of this entity. We explore the use of steroids and NSAIDs in detail and discuss evidence for various immunomodulatory agents.

A case of nodular episcleritis mimicking a solitary giant episcleral mass

PURPOSE

To describe an atypical nodular episcleritis mimicking a solitary giant episcleral mass, which is not attributed to any systemic diseases and identified only after immunohistochemical examination.

CASE REPORT

A sixty-year-old Chinese woman with systemic hypertension presented with 6-month history of giant, solitary and redness epibulbar mass arising from the superior aspect of her left eye. The lesion gradually enlarged, even with 6-month history of irregular topical steroid eye drops treatment. Imaging studies and laboratory test revealed a 10 mm × 8 mm episcleral mass absence of any infection indicator and autoimmune antibody changes. The mass was completely removed before its extension through the deep scleral, histopathologic examination revealed a nodular episcleritis composed of various chronic inflammatory cells infiltration. Topical steroid eye drops treatment combined with oral steroidal anti-inflammatory drugs was then administrated regularly for 1 month, and no recurrence occurred after 1-year follow-up.

CONCLUSION

Nodular anterior episcleritis is characterized by underlying chronic inflammation of the anterior episclera and can be presented as asymptomatic episcleral mass. Besides a thorough investigation systemically, tissue biopsy is required for definite diagnosis.

Systemic Immunosuppression in Cornea and Ocular Surface Disorders: A Ready Reckoner for Ophthalmologists

Purpose: Many diseases of the cornea and ocular surface are manifestations of an underlying autoimmune process and require systemic immunosuppression for their management. These cases often present to a general ophthalmologist before being referred to an ocular immunologist or rheumatologist. However, the patients do need to be followed by the ophthalmologist to assess disease progression or for management of ocular co-morbidities and for taking care of ocular complications of the disease. Undeniably, there is a certain hesitance to promptly initiate them on systemic therapy because the literature regarding the indications, dosages, and side effects of this group of drugs is vast and dispersed.The aim of this review is to provide a source of ready reference for the general ophthalmologist as well as trainees and residents, on systemic immunosuppression for corneal and ocular surface disease. Methods: This review included 153 studies which were published as randomized controlled trials, systematic reviews, or as nonrandomized comparative studies (cohort or case-control series) on the topic of systemic immunosuppression in cornea and ocular surface disorders.Results: This review provides a concise summary of both the types of drugs and the common indications where they would be indicated, along with treatment and monitoring algorithms for each specific disease condition. The most used group of drugs are corticosteroids, which have significant side effects, particularly when administered systemically or for longer periods of time. To overcome this, steroid-sparing immunosuppressants are recommended. The four main classes of immunosuppressants used today are antimetabolites, T-cell inhibitors, alkylating agents and biologic agents. This review details the use of these drugs in ocular surface inflammation, including the dosing schedule, side effects and monitoring in allergic conjunctivitis, mucous membrane pemphigoid, peripheral ulcerative keratitis, immunological rejection against corneal allografts, anterior scleritis and aqueous deficiency dry eyes. Conclusions: This review provides an uncluttered and wholesome understanding of systemic immunosuppression in cornea and ocular surface diseases, with the hope that this will serve as a ready reckoner and help bridge the gap between ophthalmology and rheumatology for the betterment of our patients.

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.

Scleritis and sclerokeratitis associated with IgA vasculitis: A case series

Purpose

To describe a case series of scleritis associated with IgA vasculitis (IgAV) at a tertiary referral center.

Observations

Three men with scleritis associated with IgAV were identified: one with anterior scleritis alone, one with anterior scleritis and peripheral ulcerative keratitis (sclerokeratitis), and one with anterior and posterior scleritis. Visual acuity was preserved except from the patient who developed posterior scleritis. Ocular pain was the main symptom at presentation. All patients had a previous history of palpable purpura, but only one was aware of his underlying IgAV. Laboratory results revealed microhematuria and proteinuria with normal urinary β₂ microglobulin levels and negative serum ANCAs. Skin or kidney biopsy demonstrated leukocytoclastic vasculitis or glomerulonephritis with dominant IgA immune deposits.

Conclusions and Importance

Although uncommon, IgAV should be included in the differential diagnosis of anterior scleritis alone or associated with peripheral ulcerative keratitis or posterior scleritis, even in systemically asymptomatic patients. Urinalysis should not be underestimated in assessment of scleritis to detect early stages of glomerular disease. Scleritis may be the first manifestation whose study may lead to the diagnosis of IgAV. Multidisciplinary approach is necessary to prevent irreversible organ damage such as renal failure.

Experience With 0.1% Tacrolimus Eye Drop for Noninfectious, Non-necrotizing Anterior Scleritis

OBJECTIVES

To report experience with 0.1% tacrolimus eye drops in the treatment of noninfectious, non-necrotizing anterior scleritis.

METHODS

This prospective, single-arm study included nine patients (4 men and 5 women; mean age=59.4 years, SD=10.5) with anterior scleritis. All patients were first treated with steroids for 1 month and then switched to tacrolimus eye drops alone. We defined baseline as the initiation of tacrolimus eye drops. Hyperemia and pain were scored before each treatment, at 1 and 2 weeks, and at 1 month after initiation of each treatment using 5 grades (0=none; 1+=mild; 2+=moderate; 3+=severe; 4+=extremely severe). Intraocular pressure (IOP) was also measured during treatment with each drug. Safety was assessed based on the severity and the incidence of adverse events.

RESULTS

The scores of hyperemia and pain had significantly decreased from baseline by 1 week after initiating tacrolimus eye drops (both P<0.05). No significant reduction was observed with steroid treatment throughout the 1-month period in both scores. Tacrolimus eye drops elicited statistically significant differences in mean IOP over the course of treatment (P=0.02). No additional medications were required to provide relief in any of the patients receiving tacrolimus treatment. No patient demonstrated infectious adverse events after initiation of tacrolimus treatment.

CONCLUSIONS

Topical tacrolimus may effectively and immediately reduce clinical signs and symptoms of noninfectious, non-necrotizing anterior scleritis in cases unresponsive to a course of topical steroid.

The clinical and pathogenic spectrum of surgically-induced scleral necrosis: A review

The onset of scleral necrosis after ocular surgery may have catastrophic ocular and systemic consequences. The two most frequent surgeries causing surgically-induced scleral necrosis (SISN) are pterygium excision and cataract extraction. Several pathogenic mechanisms are involved in surgically induced scleral necrosis. All of them are poorly understood. Ocular trauma increasing lytic action of collagenases with subsequent collagen degradation, vascular disruption leading to local ischemia, and immune complex deposition activating the complement system represents some of the events that lead to scleral necrosis. The complex cascade of events involving different pathogenic mechanisms and the patient's abnormal immune response frequently leads to delayed wound healing that predisposes the development of scleral necrosis. The management of SISN ranges from short-term systemic anti-inflammatory drugs to aggressive immunosuppressive therapy and surgical repair. Therefore, before performing any ocular surgery involving the sclera, a thorough ophthalmic and systemic evaluation must be done to identify high-risk patients that may develop SISN.

Beyond the joints, the extra-articular manifestations in rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory disease typically affecting the joints, but the systemic inflammatory process may involve other tissues and organs. Many extra-articular manifestations are recognized, which are related to worse long outcomes. Rheumatoid nodules are the most common extra-articular feature, found in about 30% of patients. Secondary Sjögren's syndrome and pulmonary manifestations are observed in almost 10% of patients, also in the early disease. Active RA with high disease activity has been associated with an increased risk of such features. Male gender, smoking habit, severe joint disease, worse function, high pro-inflammatory markers levels, high titer of rheumatoid factor, and HLA-related shared epitope have been reported as clinical predictors of occurrence of these rheumatoid complications. In addition, there is a little evidence deriving from randomized controlled trials in this field, thus the therapeutic strategy is mainly empiric and based on small case series and retrospective studies. However, considering that these extra-articular manifestations are usually related to the more active and severe RA, an aggressive therapeutic strategy is usually employed in view of the poor outcomes of these patients. The extra-articular features of RA remain, despite the improvement of joint damage, a major diagnostic and therapeutic challenge, since these are associated with a poor prognosis and need to be early recognized and promptly managed.

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.

Ocular nonsteroidal inflammatory drugs: where do we stand today?

Since their first introduction in ophthalmology, the use of NSAIDs (nonsteroidal anti-inflammatory drugs) has been exponentially expanded, with numerous therapeutic applications. Despite their controversial history, they have proven their efficacy as anti-inflammatory agents in a variety of diseases. Nowadays, NSAIDs are part of surgical protocols of the most commonly performed ophthalmic operations, such as cataract or ocular surgery. They are universally implicated in the management of conjunctivitis, retinal and choroidal disease and miscellaneous inflammatory diseases. Moreover, although linked with serious adverse events and toxicities, their therapeutic magnitude in Ophthalmology should not be affected. This review systematically portrays the variety of ocular NSAIDs available to date, along with their differences in their way of action, indications and potential side effects in various ophthalmologic conditions.

Oral mucosa for reconstructive surgery in a case of severe inflammatory necrotizing sclero-uveitis

The purpose of this case is to show the efficacy of buccal mucosa as an alternative to treat a case of severe necrotizing sclero-uveitis (NSU) associated with ocular perforation. We show a severe inflammatory NSU case that did not improve with topical treatment and scleral patch. We performed a buccal mucosa graft taken from the lower lip with excellent functional and anatomical result, with no signs of relapse of the NSU after 2 years of follow-up. Buccal mucosa can be a safe, useful, and effective alternative for the reconstruction of the scleral wall.

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.

Chiral pharmaceuticals: Environment sources, potential human health impacts, remediation technologies and future perspective

Chiral pharmaceuticals (CPs), including non-steroid anti-inflammatory drugs (NSAIDs), β-blockers and some herbicide and pesticides, are widely used in aquaculture, clinical treatment and many other fields. However, people are increasingly concerned about such ubiquitous pollutants, which can frequently be detected in contaminated soil and water. In large part, the significant sources of chiral pharmaceuticals stem from industrial processes, such as the direct discharge of untreated or incompletely treated wastewaters containing chiral pharmaceuticals, incorrect storage and use, animal wastes and biosolids. The main ways for human exposure to chiral pharmaceuticals are the disease treatment process and chiral pharmaceuticals contaminants. According to the results of a series of toxic studies, some diseases, even cancers, may be associated with exposure to certain chiral pharmaceuticals. Therefore, the treatment of chiral pharmaceuticals has become an important issue. The current advanced remediation techniques for chiral pharmaceuticals include the conventional method (sorption and sonolysis), biotransformation (an aerobic granular sludge-sequencing batch reactor and constructed wetland system) and advanced oxidation processes (ozonation and photocatalysis). Herein, in this review, we summarize the current status and sources of chiral pharmaceuticals, potential effects on human health, as well as the superiority, disadvantages and prospects of current advanced remediation technologies. Moreover, we also anticipate the prospect of the future research needed for chiral pharmaceuticals pollutant remediation.

Efficacy and safety of immunomodulatory drugs in patients with anterior uveitis: A systematic literature review

BACKGROUND

To assess the efficacy and safety of immunomodulatory drugs in patients with noninfectious anterior uveitis (AU).

METHODS

Systematic review of studies were retrieved from Medline (1961 to March 2016), Embase (1961 to March 2016), and Cochrane Library (up to March 2016), and a complementary hand search was also performed. The selection criteria were as follows: (population) noninfectious AU patients, adults; (intervention) immunomodulatory drugs (any dose, regimen, route of administration, duration of treatment); (outcome) control of inflammation, steroid-sparing effect, AU flares, adverse events, and so on; (study design) systematic literature reviews, randomized controlled trials, and observational studies. The study quality was assessed using the Jadad scale and according to The Oxford Centre for Evidence-based Medicine (update 2009).

RESULTS

We included 13 studies of moderate-poor quality, with a mean duration from 5 months to 20 years, and number of AU patients ranging from 9 to 274. Patient's demographic and clinical characteristics were very heterogeneous. In most cases, uveitis anatomic classification criteria and outcomes definitions were unclear. Some of the studies only included AU patients with a systemic disease associated, mostly spondyloarthritis, others, mixed populations (idiopathic and systemic disease associated patients), and in some articles this data is not described. We found that methotrexate, cyclosporine A, azathioprine, adalimumab, and golimumab might prevent AU flares, improve ocular inflammation and visual acuity, and decrease systemic steroids doses.

CONCLUSIONS

Although there is a lack of robust evidence, methotrexate, cyclosporine A, azathioprine, adalimumab, and golimumab might be effective in AU patients.

[Scleritis and episcleritis]

Episcleritis is generally a benign disease with a self-limited course, while scleritis is a severe ocular condition due to a risk of impaired vision in one-fifth of patients and its association with systemic diseases in one third of them. Infectious scleritis, representing 8 % of the etiologies, is mainly of herpetic origin (varicella zoster and herpes simplex viruses). A systemic autoimmune disease is observed in roughly 30 % of scleritis patients: inflammatory rheumatisms (15 %), firstly rheumatoid polyarthritis, systemic vasculitides (8 %), mainly granulomatosis with polyangiitis (Wegener's) and polychondritis, and less often inflammatory bowel disease and systemic lupus erythematosus. Among the different types of scleritis, a clear distinction exists between necrotizing forms leading to decreased vision in 50 % of the cases and associated with systemic diseases in the vast majority, and non-necrotizing forms (either diffuse or nodular), with a better prognosis. However, recent publications show that necrotizing forms are much less frequent nowadays (around 5 % of the total), probably due to therapeutic innovations and progress made during the last 20 years. The medical management of scleritis requires collaboration between ophthalmologists and internists (or rheumatologists).

Ocular Pharmacology for Scleritis: Review of Treatment and a Practical Perspective

Scleritis is defined as an infectious or noninfectious inflammation of the sclera that can be broadly categorized according to anatomic location (ie, anterior or posterior) and whether the process is necrotizing or non-necrotizing. Treatment for scleritis is dictated by the etiology of the inflammation, with infectious forms requiring treatment of the inciting agent and noninfectious forms requiring treatment of the underlying inflammation with immunosuppression. Pharmacotherapy for noninfectious scleritis can be classified according to delivery route (eg, local or systemic) and mechanism of action (eg, biologic or nonbiologic). This review will briefly summarize the classification scheme for scleritis before reviewing in depth both systemic and local pharmacotherapies that can be used to effectively treat an eye afflicted by either infectious or noninfectious scleritis. Traditional anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs, steroids, and immunomodulatory therapy will be discussed, as well as newer biologic therapies such as antitumor necrosis factor alpha and anti-CD20 agents.

Tailored treatment for the management of scleral necrosis following pterygium excision

The present study aimed to investigate the efficacy of tailored treatment for the management of scleral necrosis following pterygium surgery. A series of nine cases of scleral necrosis following pterygium excision between September 2009 and September 2012 were included. In cases where ischemia was the cause of scleral necrosis, Tenon's membrane covering (TMC) surgery was performed. For cases with surgically-induced necrotizing scleritis (SINS), systemic immunosuppressive therapy following surgical repair of the scleral defect was administered in the form of oral prednisolone (starting dose, 30–60 mg/day). Five patients with ischemic scleral necrosis received TMC postoperatively. Four patients with SINS received various doses of oral prednisolone according to their systematic immune state. All patients had successful postoperative results except one with rheumatoid arthritis, who postoperatively developed scleral patch graft melting within 2 weeks. Following aggressive immunosuppressive treatment, the scleral patch graft was saved. In conclusion, patients achieved positive results using tailored treatment according to the pathogenesis of their scleral necrosis.

Clinical Features and Complications of Scleritis in Chinese Patients

PURPOSE

To characterize the clinical features of scleritis in Chinese patients.

METHODS

The history, demographics, ocular findings, auxiliary examination findings, complications, systemic diseases and therapeutic effects were analyzed retrospectively.

RESULTS

The study included 124 male and 169 female patients with scleritis. Anterior and posterior scleritis were, respectively, found in 243 and 42 patients. The other eight patients had both anterior and posterior involvement. The mean age of scleritis onset was 39.4 years. Systemic diseases associated with scleritis mainly included rheumatoid arthritis (RA) (4.4%), ankylosing spondylitis (AS) (3.4%), and tuberculosis (1.7%). Anterior uveitis (23.7%), complicated cataract (16.7%), and intraocular hypertension (12.6%) were common complications of scleritis. Scleritis was controlled in 94.6% of the patients treated with corticosteroids combined with immunosuppressive agents.

CONCLUSIONS

Diffuse anterior scleritis was the most common scleritis entity in China. RA and AS were relatively common diseases associated with scleritis. Corticosteroids combined with immunosuppressive agents effectively controlled the disease.

Intravitreal dexamethasone implants for the treatment of refractory scleritis combined with uveitis in adult-onset Still's disease: a case report

Background

Adult-onset Still’s disease is a systemic inflammatory disease which presents with uveitis and scleritis in the eye. Intravitreal dexamethasone implants are used for the treatment of refractory uveitis.

Case presentation

A 19-year-old woman diagnosed to have adult-onset Still’s disease for fevers, joint pain, and a salmon-colored bumpy rash presented with scleritis and uveitis in the left eye. Topical and systemic steroids with oral methotrexate failed to control the inflammation. We performed intravitreal injections of dexamethasone implants for side effects of steroid and refractory ocular inflammation. The therapy resulted in improvements in the patient’s uveitis with reductions in scleral vessel engorgement and redness. There was no recurrence of uveitis or scleritis during 4 months following treatment.

Conclusions

Intravitreal injections of dexamethasone implants may result in clinical improvements of refractory scleritis combined with uveitis.

Clinical Profile of Patients with Necrotizing Scleritis in a Tertiary Eye Care Center in Southern India

PURPOSE

To report the clinical profile of a series of necrotizing scleritis in an Indian population.

METHODS

A retrospective medical record review of 27 consecutive patients with necrotizing scleritis. Patient demographics, ocular and systemic findings, treatment modalities, and visual outcome were recorded.

RESULTS

There were 19 males and 8 females (31 eyes) with mean age at presentation of 49.5 years (range: 30-84 years). Underlying immunologically induced disorders was present in 37%. In 70% of the cases with immunologically induced disorders, necrotizing scleritis was the initial presentation. Complicated cataract (25.8%) and exudative retinal detachment (9.6%) were the most common anterior and posterior segment complications, respectively. Cyclophosphamide was the most commonly used immunosuppressive (55.56%) and proved to be the most effective. But even with the best available treatment, globe perforation was encountered in two eyes.

CONCLUSIONS

Necrotizing scleritis can be the initial presentation of immunologically induced disorders. This disease entity is plagued with a high rate of ocular complications, especially those which can be devastating, such as globe perforation. Early and intensive therapy can be helpful in salvaging the eye.

Uveitis Specialists and Rheumatologists Select Different Therapies for Idiopathic Non-necrotizing Anterior Scleritis

Introduction

Uveitis specialists and rheumatologists treat patients with anterior scleritis, but data from controlled trials to guide management are scarce, making differences in treatment paradigms possible.

Methods

1044 uveitis specialists and rheumatologists were surveyed regarding therapy for a patient with anterior scleritis. Respondents were asked to select first- and second-choice therapies and then reselect therapies assuming that the costs of all options were equal and that insurance approval was ensured. Fisher’s exact tests were employed to compare selections.

Results

Ninety-two respondents (8.6%) completed the survey. Methotrexate was the most-selected first-choice treatment before equalization of cost/insurance factors among uveitis specialists (44.4%) and rheumatologists (78.6%) (p < 0.009). Uveitis specialists selected mycophenolate at a higher rate (27.8%) than did rheumatologists (5.3%) (p < 0.015). Cost and insurance considerations were not significant.

Conclusions

Uveitis specialists and rheumatologists have different preferences in the treatment of anterior scleritis. The difference is impacted more by specialty practice than by cost/insurance.

Interleukin-22 serum levels are elevated in active scleritis

PURPOSE

To evaluate serum cytokine profile from patients with active scleritis in a two-centre prospective case-control study.

METHODS

The serum of 20 active scleritis patients not treated with any local, periocular, or systemic immunomodulatory therapy (IMT) was analysed with multiplex assay to determine the levels of 11 cytokines interleukin (IL)-1β, IL-6, IL-2, IFN-γ, IL-10, IL-12p40, IL-13, IL-17A, IL-5, TNF-α, and TNF-β, and with ELISA to determine the levels of TGF-β1, IL-22, and IL-23. Twenty-five age-matched healthy volunteers were used as controls. In a subgroup of 13 patients with active disease, a second serum sample was obtained when the disease was inactive and levels of IL-22 were determined. Serum IL-22 levels from patients with active scleritis were correlated with type of scleritis (non-necrotizing and necrotizing), degree of inflammation (0-4+ :≤2+ and >2+), and associated systemic disease.

RESULTS

Serum levels of IL-22 were elevated in active scleritis patients compared to controls (6.41 ± 1.52 pg/ml versus 1.93 ± 0.39 pg/ml, p = 0.012) and significantly decreased after scleritis remission with the use of IMT (p = 0.005). There was no statistical association with scleritis type, degree of inflammation, or associated systemic disease. The serum levels of other cytokines were not significantly different from controls.

CONCLUSION

In our study cohort, IL-22 serum levels were significantly elevated in active scleritis patients compared to controls and decreased significantly after remission. Our results suggest that IL-22, a T helper (Th) 17- and Th22- derived cytokine, may play a critical role in the physiopathology of scleritis.

High-resolution ultrasound biomicroscopy as an adjunctive diagnostic tool for anterior scleral inflammatory disease

PURPOSE

To study high-resolution ultrasound biomicroscopy (UBM) findings in anterior scleral inflammatory disease and evaluate the efficacy of high-resolution UBM as an adjunctive diagnostic tool.

METHODS

A cross-sectional study. The medical records of 30 patients (33 eyes) with episcleritis or anterior scleritis were reviewed for clinical features and high-resolution UBM findings. Ultrasound biomicroscopy (UBM) examination was performed using 50 MHz Aviso S (Quantel Medical, Clermont-Ferrand, France).

RESULTS

Seventeen eyes had episcleritis [nodular (12), simple (five)], and 16 eyes had anterior scleritis [nodular (14), diffuse (two)] as classified by UBM. The use of high-resolution UBM allowed high-resolution imaging of the sclera and episclera and showed characteristic patterns of episcleritis and anterior scleritis. The clinical classification matched UBM findings in 25 (76%) eyes. In the other eight eyes (24%), UBM analysis led to a change in the final classification: four eyes with suspected episcleritis were classified with scleritis, and four eyes with suspected scleritis were classified with episcleritis. Eleven patients (36.7%) had an associated systemic disease.

CONCLUSION

High-resolution UBM enabled visualization of distinct imaging findings of episcleritis and anterior scleritis, indicating its usefulness in the classification of challenging cases of anterior scleral inflammatory disease.

Posterior scleritis in pediatric age group: A case report and review of literature

Posterior scleritis is rare in both the adult and pediatric age groups. Increased awareness and availability of advanced diagnostic facilities aid in early diagnosis and management. Visual recovery is possible with systemic steroids and immunosuppression. We report the case of a 12-year-old male child who presented with poor vision in his right eye and was found to have retinal striae and disc edema due to posterior scleritis.