Rituximab Therapy for Refractory Scleritis

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.

PARADOXICAL EXACERBATION OF SCLEROUVEITIS AFTER RITUXIMAB INFUSION

PURPOSE

To report on an unexpected side effect of rituximab, a B-cell-targeting monoclonal agent, in a patient with severe sclerouveitis, leading to severe visual loss.

METHODS

Observational case report.

RESULTS

A 61-year-old female patient was treated with rituximab for a severe sclerouveitis occurring with granulomatosis with polyangiitis. Initially, sclerouveitis responded partly to a high dose of oral corticosteroids. However, her sclerouveitis recurred after 2 months during tapering below 20 mg daily. The days following the rituximab infusions, aggravation of the intraocular inflammation was seen, endangering visual acuity. No evidence for an infection or other cause was found. High doses of oral corticosteroids were started within one week, whereafter the ocular inflammation resolved. For persisting hypotony and chorioretinal detachment, a combined pars plana vitrectomy with phacoemulsification and silicone oil tamponade was performed. The retina remained attached under oil tamponade with partial improvement of the best-corrected visual acuity to finger counting.

CONCLUSION

Ophthalmologist should be aware of the possibility of this paradoxical local reaction to rituximab infusion, particularly in bilateral and/or severe cases, which carry a risk of a poor outcome.

Long-Term Follow-Up of Patients with Scleritis After Rituximab Treatment Including B Cell Monitoring

PURPOSE

We report the long-term effect of rituximab (RTX) in scleritis and determine the value of B-cell monitoring for the prediction of relapses.

METHODS

We retrospectively studied 10 patients with scleritis, who were treated with RTX. Clinical characteristics were collected, and blood B-cell counts were measured before the start of RTX, and at various time points after treatment.

RESULTS

Clinical activity of scleritis decreased after RTX treatment in all patients within a median time of 8 weeks (range 3-13), and all reached remission. The median follow-up was 101 months (range 9-138). Relapses occurred in 6 out of 10 patients. All relapses, where B-cell counts were measured (11 out of 19), were heralded by returning B cells. However, B cells also returned in patients with long-term remissions.

CONCLUSIONS

RTX is a promising therapeutic option for scleritis. Recurrence of B cells after initial depletion does not always predict relapse of scleritis.

Efficacy and safety of Janus kinase inhibitors in non-infectious inflammatory ocular diseases: a prospective cohort study from the international AIDA network registries

Introduction

Non-infectious inflammatory ocular diseases pose significant challenges in diagnosis and management, often requiring systemic immunosuppressive therapy. Since Janus kinase (JAK) inhibitors may represent a novel therapeutic option for these disorders, the present study aimed to expand current knowledge about their efficacy and safety in patients with these conditions.

Methods

This prospective cohort study included 12 adult patients from the international AutoInflammatory Disease Alliance (AIDA) Network registries dedicated to non-infectious ocular inflammatory conditions. We assessed ocular flares, visual acuity, disease course, and complications before and after initiating JAK inhibitor therapy.

Results

Ocular inflammation was related to a systemic disease in 8 (66.7%) patients as follows: spondyloarthritis (n = 3), peripheral psoriatic arthritis (n = 1), rheumatoid arthritis (n = 1), antinuclear antibodies (ANA) positive juvenile idiopathic arthritis (n = 1), Behçet's syndrome (n = 1), Vogt-Koyanagi-Harada syndrome (n = 1). In total, 4 patients received baricitinib, 1 patient received tofacitinib, and 7 patients underwent upadacitinib treatment. The overall average duration of JAK inhibitors treatment was 8.6 ± 5.5 months (ranging from 3 to 20 months). At the last assessment, ocular disease control was complete in 12/12 patients. One patient discontinued baricitinib due to poor compliance after a 12-month relapse-free period. The incidence of ocular flares was 125 episodes/1.000 person-months prior to the initiation of JAK inhibitors and 28.6 episodes/1.000 person-months thereafter. The incidence rate ratio for experiencing a relapse before starting a JAK inhibitor compared to the following period was 4.37 (95% CI 1.3-14.7, p-value: 0.02).

Conclusion

JAK inhibitors demonstrate efficacy and safety in controlling ocular inflammatory relapses, confirming that they represent a valuable treatment option for patients with non-infectious inflammatory ocular diseases resistant to conventional treatments.

The Role of Biologic Agents in the Management of Pediatric-Onset Noninfectious Posterior Scleritis

Registry-based observational prospective study aimed at describing the use of biologic drugs in pediatric-onset scleritis. Data were collected at baseline, at 3-, 6-, 12-month follow-up and at last assessment. Scleral inflammation was graded according to Sen classification. Five patients (9 eyes) treated with adalimumab, infliximab, abatacept and secukinumab were included. All patients were previously treated with conventional immunosuppressors and glucocorticoids. Median biologic treatment duration was 28 (IQR = 118) months. At 6-months, scleritis resolved in all eyes. At 12-months, complete disease control was observed in 7/9 eyes (77.8%). The number of relapses 12 months before and after treatment initiation was 17 and 2, respectively. Mean BCVA was 0.83 (range 0.3-1.0) at baseline and 1.0 for all eyes after 12 months. Glucocorticoids had been withdrawn in 4/5 patients.In conclusion, biological agents proved to be effective in pediatric-onset scleritis, allowing a noticeable steroid-sparing effect and preserving visual function and bulbar integrity.

Effectiveness of difluprednate in addition to systemic therapy for the treatment of anterior scleritis

AIM

To describe the effectiveness and side-effect profile of adding difluprednate therapy to patients with anterior scleritis being treated systemically.

METHODS

Retrospective chart review. Charts from all patients with anterior scleritis who were treated with topical difluprednate in addition to systemic therapy from 1 January 2018 to 1 January 2020 were reviewed. Data collected included: demographics, scleritis type, systemic diagnosis, presence of nodules or necrosis, changes in scleritis activity, intraocular pressure (IOP), number of difluprednate drops used, type of systemic treatment used, best-corrected visual acuity (BCVA) and lens status. The primary outcome was clinical resolution of scleritis. Secondary outcomes included BCVA loss ≥2 lines, change in lens status or cataract surgery and IOP ≥24 mm Hg.

RESULTS

Thirty-two patients (44 eyes) were analysed. The median age was 57 years (IQR 52, 72); 59% were female; 72% were Caucasian. An associated systemic disease was present in 59%. Systemic therapies used when difluprednate was added were: 65% immunosuppressive agents, 43% prednisone and 25% non-steroidal anti-inflammatory drugs. The addition of difluprednate resulted in clinical resolution in 79.6% of the treated eyes. Median time to inactivity was 9 weeks (IQR 5, 20). Eyes initially using 2-4 drops per day had a higher response rate (89%, p=0.005). Over a median follow-up of 34 weeks (IQR 21, 74), 11 eyes had IOP elevation; 6 eyes lost ≥2 lines of BCVA, 5 eyes had cataract progression.

CONCLUSION

Most eyes treated with difluprednate achieved inactivity. The addition of difluprednate to systemic therapies provides an alternative to achieve control of inflammation.

[Scleritis and episcleritis]

Scleritis and episcleritis are rare ocular inflammatory diseases but deserve to be known by internists because of their frequent association with systemic autoimmune diseases. It is important to distinguish them between because their prognosis, therapeutic management and potential complications are very different. Episcleritis represents a superficial ocular inflammation with usually benign visual prognosis, no complication with local treatment, and is associated with a systemic autoimmune disease in rare cases. In contrast, scleritis is a potentially serious ophthalmological condition that can threaten the visual prognosis in the absence of appropriate systemic treatment. It is associated with an underlying disease in 40-50% of cases, in particular a systemic autoimmune disease (25-35% of cases) or an infectious cause (5-10% of cases). Rheumatoid arthritis and systemic vasculitides, particularly antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides, are the main autoimmune causes of scleritis and episcleritis. Scleritis can reveal the underlying autoimmune disease and requires systematic etiological investigations. Aggressive, complicated, refractory forms or those associated with a systemic autoimmune disease require glucocorticoids or even immunosuppressants, and close collaboration between ophthalmologists and internists is required. The development of biologic agents offers new effective therapeutic tools in the management of these difficult cases.

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.

Peripheral Subretinal Mass Complicating Necrotizing Anterior Scleritis in a Patient with Granulomatosis with Polyangiitis

Anterior scleritis is rarely diagnosed with a peripheral amelanotic subretinal mass. We reported a rare case of a 31-year-old woman who was referred for suspected left eye choroidal melanoma. The patient had granulomatosis with polyangiitis with a history of treated left eye necrotizing anterior scleritis. Her left eye examination revealed 20/60 vision, superotemporal diffuse scleral injection, and thinning. Dilated fundus examination of the left eye showed a large peripheral amelanotic subretinal mass below the area of anterior scleritis, optic disc hyperemia, and subretinal fluid. The patient was successfully treated with intravenous methylprednisolone, rituximab infusions, and oral methotrexate. Two months after treatment, her vision improved to 20/20, with inactive anterior scleritis and a significant reduction in the subretinal mass with complete resolution of optic disc hyperemia and subretinal fluid. High index of suspicion of this atypical presentation of anterior scleritis is important to avoid aggressive modalities of treatment.

An update on long-acting therapies in chronic sight-threatening eye diseases of the posterior segment: AMD, DMO, RVO, uveitis and glaucoma

In the real-world setting, there is suboptimal compliance with treatments that require frequent administration and assessment visits. This undertreatment frequently has negative consequences in eye disease and carries a real risk to vision. For example, patients with glaucoma risk progression of visual loss even with a small number of missed doses, and patients with neovascular age-related degeneration (nAMD) who fail to attend a bi-monthly clinic appointment to receive an intravitreal anti-vascular endothelial growth factor (VEGF) drug injections may lose the initial vision gains in vision. Protracted regular treatment schedules represent a high burden not only for patients and families, but also healthcare professionals, systems, and ultimately society too. There has been a clear need for longer-acting therapies that reduce the frequency, and therefore the burden, of treatment interventions. Several longer-acting interventions for nAMD, diabetic macular oedema, retinal vein occlusion, uveitis and glaucoma have either been developed or are in late-phase development, some of which employ novel mechanisms of actions, and all of which of promise longer (≥3 month) treatment intervals. This review delivers an overview of anti-VEGF agents with longer durations of action, DARPins, bispecific anti-VEGF/Ang2 therapies, anti-PDGF and anti-integrin therapy, Rho-kinase inhibitors, the Port Delivery System, steroids, gene therapy for retina and uveitis, and for glaucoma, ROCK inhibitors, implants and plugs, and SLT laser and MIGS. The review also refers to the potential of artificial intelligence to tailor treatment efficacy with a resulting reduction in treatment burden.

Therapie der Uveitis mit Biologika

Zielsetzung Ziel dieser Zusammenfassung ist das Vermitteln einer Übersicht zu den verschiedenen Ansatzpunkten, Wirkmechanismen und Indikationen diverser Biologika, die bei der Therapie der nichtinfektiösen Uveitis zum Einsatz kommen.

Material und Methoden Etablierte sowie aktuelle Literatur wurden herangezogen, um die biochemischen und pathophysiologischen Grundlagen sowie eine evidenzbasierte Empfehlung zum Therapieeinsatz verschiedener Biologika bei nichtinfektiöser Uveitis allgemein und bei speziellen Uveitisentitäten darzulegen.

Ergebnisse Für viele Biologika, hier nennenswert TNF-α-Inhibitoren, einige Interleukininhibitoren, Interferone sowie B- und T-Zell-Inhibitoren, liegen mittlerweile gute Daten vor, was ihren Einsatz in der Uveitistherapie mehr als rechtfertigt. Dies trifft insbesondere für den TNF-α-Inhibitor Adalimumab zu, welcher der einzig zugelassene Vertreter für diese Indikation unter den vorgestellten Biologika ist.

Schlussfolgerungen Die Biologika haben die Behandlung der Uveitis revolutioniert und sind aus der aktuellen Therapie der intraokularen Entzündung nicht mehr wegzudenken. Biologika werden bei Ineffektivität oder Unverträglichkeit konventioneller immunsuppressiver Medikamente empfohlen, aber auch bei der Therapie von schwerwiegenden Uveitisformen (z. B. Morbus Behçet). Die TNF-α-Inhibitoren sind die am häufigsten verwendeten Biologika bei Uveitis.

Peripheral Ulcerative Keratitis in a Young Lady with Systemic Lupus Erythematosus Post Rituximab Infusion-A Case Report

AIM

We report a new ocular finding of episcleritis (OD) and peripheral ulcerative keratitis (OS) in a 40-year-old lady with a 13-year history of systemic lupus erythematosus (SLE), 3 weeks post-rituximab infusion.

MATERIALS & METHODS

Retrospective case report.

RESULTS

A 40-year-old lady with a history of SLE and 3 weeks post rituximab infusion developed a new onset episcleritis (OD) and peripheral ulcerative keratitis (OS). As the PUK continued to advance with a leading edge, intravenous methyl prednisolone 1 gm/day was given for 3 days followed by a slow tapering course of oral prednisolone 50 mg/day. Though her ocular inflammation resolved, she developed pneumonia 6 weeks later. At 10 months follow-up, there were no ocular recurrences. She is currently on mycophenolate mofetil 2 gm/day along with oral prednisolone of 10 mg/day.

CONCLUSION

This case highlights the new occurrence of episcleritis and PUK in SLE post-rituximab infusion.

Subconjunctival Rituximab Administration for the Treatment of Scleritis

PURPOSE

Scleritis is a sight-threatening inflammation, which is commonly accompanied by severe complications. Aggressive systemic immunosuppressive treatment, which is frequently needed, can be associated with serious complications, and might therefore be (temporarily) contraindicated.

METHODS

We report on the outcomes of three patients with severe, active, non-infectious scleritis, refractory or intolerant to systemic treatment, who received subconjunctival rituximab (RTX) injections. A dose of 2.5 to 7.5 mg was administered after topical anesthesia, and follow-up varied from 8 to 10 months.

RESULTS

Subconjunctival RTX showed minimal to no effect on subjective symptoms, clinical features and/or ultrasound images. No serious adverse effects occurred.

CONCLUSION

Further studies are needed to assess the effect of local administration of RTX in scleritis, but our limited observation is not promising.

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.

Role of Janus Kinase (JAK) Inhibitor in Autoimmune Ocular Inflammation: A Systematic Review

Purpose

To evaluate the effectiveness of Janus kinase (JAK) inhibitors for the treatment of patients with autoimmune disease and associated inflammatory ocular diseases.

Methods

We identified relevant literature by screening the MEDLINE, PubMed, and Cochrane databases for randomized controlled trials, cohort studies, case controls, and case reports.

Results

Seven studies, including 11 patients, were included in the final systematic analysis. Of the 11 patients, there were 5 cases of juvenile idiopathic arthritis- (JIA-) associated uveitis, 1 case of rheumatoid arthritis- (RA-) associated keratitis, 1 case of RA-associated scleritis, 1 case of psoriasis-associated conjunctivitis, 2 cases of noninfectious scleritis, and 1 case of uveitis with suspected autoimmune disease. None of these 11 patients responded adequately to conventional treatments, including biological agents; these were all refractory cases and switched to JAK inhibitor therapy. Irrespective of whether they were suffering from uveitis, scleritis, or other types of ocular inflammation, all 11 patients showed an improvement to JAK inhibitors without significant side effects. Different types of JAK inhibitors might be associated with different responses when used to treat ocular inflammation.

Conclusions

JAK inhibitors may represent an alternative treatment option for patients with autoimmune ocular inflammation.

A review of ophthalmic manifestations of inflammatory bowel disease and associated treatments

PURPOSE OF REVIEW

To review the ocular manifestations of inflammatory bowel disease (IBD) and the treatments for each of these, including novel therapies and their effects on uveitis. With the advent of newer treatments for ulcerative colitis and Crohn's disease, it is important to investigate whether these therapies have beneficial effects for extraintestinal manifestations (EIM) of IBD, in particular, ocular manifestations.

RECENT FINDINGS

The newer treatments for IBD, including biologics, such as golimumab (Simponi), certolizumab (Cimzia), vedolizumab (Entyvio), and interleukin (IL) receptor inhibitors, such as ustekinimab (Stelara), could potentially have treatment benefits for patients with uveitis and IBD.

SUMMARY

Ocular manifestations of IBD are important to detect early and treat appropriately. With novel treatments for IBD, it is important to further study whether these therapies have benefits for ocular manifestations of IBD, such as uveitis. Future clinical trials need to be conducted to investigate this.

Ocular Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is characterized by intestinal inflammation; however, it is also known to have extraintestinal manifestations. Ocular manifestations of IBD include keratopathy, episcleritis, scleritis, and uveitis and are among the most common extraintestinal manifestations. These diseases can lead to significant ocular morbidity if unrecognized and left untreated. A review of the literature was performed on PubMed and is summarized and critically appraised in this article with the aim being to describe the varying ocular manifestations of IBD and outlining their treatments. Ultimately, a framework is provided to investigate ocular symptoms in patients with IBD. An ocular review of systems is also provided as a tool to equip gastroenterologists and internal medicine physicians to be able to recognize and triage ocular complaints appropriately.

Biologic Therapies and Small Molecules for the Management of Non-Infectious Scleritis: A Narrative Review

Scleritis refers to a wide spectrum of ocular conditions ranging from mild to sight-threatening scleral inflammation that may compromise visual function and threaten the anatomical integrity of the ocular globe. Most aggressive forms like necrotizing or posterior scleritis are often difficult-to-treat cases, refractory to conventional treatment. The association with systemic diseases, namely rheumatoid arthritis, Sjögren syndrome, granulomatosis with polyangiitis, and relapsing polychondritis, may have prognostic implications as well. A better understanding of the pathogenesis of ocular inflammatory diseases have paved the way to more effective and targeted treatment approaches. In this regard, a growing body of evidence supports the potential role of biologic agents in the management of non-infectious scleral inflammation, either idiopathic or in a background of immune-mediated systemic disorders. Biologic agents such as anti-tumor necrosis factor agents, interleukin-1 and interleukin-6 inhibitors as well as CD20 blockade have displayed promising results. More specifically, several studies have reported their ability to control scleral inflammation, reduce the overall scleritis relapses, and allow a glucocorticoid-sparing effect while being generally well tolerated. Anecdotal reports have also been described with other biologic agents including abatacept, ustekinumab, daclizumab, and alemtuzumab as well as targeted small molecules such as tofacitinib. Further studies are warranted to fully elucidate the role of biologic agents in non-infectious scleritis and investigate specific areas with the aim to administer treatments in the context of personalized medicine. This review summarizes the available data regarding clinical trials, small pilot studies, and real-life experience of the last two decades reporting the use of biologic agents in the management of non-infectious scleritis.

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.

Rituximab for non-infectious Uveitis and Scleritis

Purpose

To provide a comprehensive review of rituximab use for the treatment of non-infectious uveitis and scleritis.

Methods

Review of literature through December 2020.

Results

Individual data was available for 229 patients with refractory non-infectious uveitis (n = 108) or scleritis (n = 121) who received treatment with rituximab (RTX). Rituximab was generally utilized as third-line or later treatment (uveitis: 67/90, 74.4%; scleritis: 90/96, 93.8%) at a mean of 33.5 months following the diagnosis of uveitis (range = 0 to 168.0 months; median = 24.0 months) and 39.4 months after diagnosis of scleritis (range = 1.0 to 168.0 months; median = 21.0 months). Patients with non-infectious uveitis and scleritis either received prior treatment with corticosteroids only (uveitis: 18/90, 20%; scleritis: 4/94, 4.3%), or with one (uveitis: 19/90, 21.1%; scleritis: 30/94, 31.9%), two (uveitis: 11/90, 12.2%; scleritis 27/94, 28.7%), or three or more (uveitis: 37/90, 41.1%; scleritis: 31/94, 33.0%) corticosteroid-sparing immunosuppressive agents with or without corticosteroids before initiation of RTX treatment. The rheumatologic protocol (two infusions of 1 gram of RTX separated by 14 days) was utilized most frequently (uveitis: 45/87, 51.7%; scleritis: 87/114, 76.3%), followed by the Foster protocol (eight weekly infusions of 375 mg/m² RTX; uveitis: 18/87, 20.7%; scleritis: 10/114, 8.8%), and the oncologic protocol (four weekly infusions of 375 mg/m² RTX; uveitis: 5/87, 5.7%; scleritis: 6/114, 5.3%). Various other off-label regimens were used infrequently (uveitis: 19/87, 21.8%; scleritis 11/114, 9.6%). Rituximab treatments resulted in a positive therapeutic response for the majority of patients with non-infectious uveitis (81/97, 83.5%). Commonly treated uveitic diagnoses included non-paraneoplastic autoimmune retinopathy (30/107, 28.0%), juvenile idiopathic arthritis (21/107, 19.6%), Vogt-Koyanagi-Harada disease (12/107, 11.2%), and Behçet disease (11/107, 10.3%). Cases of non-infectious scleritis were most commonly attributed to granulomatosis with polyangiitis (75/121, 62.0%) and rheumatoid arthritis (15/121, 12.4%), and showed an even greater rate of positive therapeutic response (112/120, 93.3%) following RTX treatment. No side effects were reported in 76.3% (74/97) of uveitis and 85.5% (71/83) scleritis cases. Of those cases associated with RTX-induced adverse events, the most common were infusion reactions of various severity (11/35, 31.4%).

Conclusions

Overall, RTX appeared to be both effective and well-tolerated as second or third-line therapy for patients with non-infectious uveitis and scleritis.

Biological therapy in refractory cases of uveitis and scleritis: An analysis of 18 cases from a tertiary eye care center from South India

Purpose

To evaluate the effectiveness of biologic therapy in a cohort of patients with various types of refractory non-infectious uveitis and scleritis.

Methods

A retrospective observational study on patients with non-infectious uveitis and scleritis who were not responding or had a high recurrence rate with the conventional treatment and had received biologic therapy.

Results

We studied 18 patients (33 eyes) who received biological therapy between January 2017 and November 2019. The mean age was 30 ± 17 years and mean duration of uveitis was 36.8 months (range 1-120 months). Anterior uveitis (27.7%) was most commonly observed followed by scleritis, panuveitis, posterior, and intermediate uveitis. The most common etiology was Behçet's disease (4 patients, 22.2%) followed by juvenile idiopathic arthritis (3 patients, 16.6%), granulamotosis polyangitis, and idiopathic (2 patients each, 11.1%). Majority had trialled one or more immunosuppressive and were refractory in nature. Maximum patients had received adalimumab (61%) followed by infliximab (22%), rituximab (12%), and golimumab (6%). The median prednisolone dose was reduced from 30 mg (range 7.5-60 mg) to 5 mg (range 0-10 mg) after biological therapy (P = 0.002). Significant visual improvement was observed post biologic therapy (mean log mar VA 0.41 ± 0.62 improved to 0.23 ± 0.48 at the final visit, P = 0.008). Maximum number of patients (16 patients, 89%) responded well with biological therapy. Three patients developed recurrence and systemic complications were observed in two patients.

Conclusion

Biologic therapy is effective in non-infectious refractory uveitis who were resistant to conventional therapy and may prolong disease recurrence.

Rheumatoid Arthritis Associated Episcleritis and Scleritis: An Update on Treatment Perspectives

Episcleritis and scleritis are the most common ocular inflammatory manifestation of rheumatoid arthritis. Rheumatoid arthritis (RA) accounts for 8% to 15% of the cases of scleritis, and 2% of patients with RA will develop scleritis. These patients are more likely to present with diffuse or necrotizing forms of scleritis and have an increased risk of ocular complications and refractory scleral inflammation. In this review we provide an overview of diagnosis and management of rheumatoid arthritis-associated episcleritis and scleritis with a focus on recent treatment perspectives. Episcleritis is usually benign and treated with oral non-steroidal anti- inflammatory drugs (NSAIDs) and/or topical steroids. Treatment of scleritis will classically include oral NSAIDs and steroids but may require disease-modifying anti-rheumatic drugs (DMARDs). In refractory cases, treatment with anti TNF biologic agents (infliximab, and adalimumab) is now recommended. Evidence suggests that rituximab may be an effective option, and further studies are needed to investigate the potential role of gevokizumab, tocilizumab, abatacept, tofacitinib, or ACTH gel. A close cooperation is needed between the rheumatology or internal medicine specialist and the ophthalmologist, especially when scleritis may be the first indicator of an underlying rheumatoid vasculitis.

Worsening of posterior scleritis and orbital pseudotumor in a patient with granulomatosis polyangiitis with rituximab-A case report

We report a case of exacerbation of posterior scleritis and orbital pseudotumor in a patient with granulomatosis polyangiitis, with initial rituximab infusion. Modifications in rituximab protocols including reduction in maintenance dose for subsequent infusions with increase in premedication dose of intravenous methyl prednisolone may be useful to prevent periinfusional flares. In this case report, we highlight a rare occurrence and modification in rituximab protocol to prevent post-infusional flare of inflammation.

Remission of Non-Infectious Anterior Scleritis: Incidence and Predictive Factors

PURPOSE

To assess how often non-infectious anterior scleritis remits and identify predictive factors.

METHODS

Our retrospective cohort study at four ocular inflammation subspecialty centers collected data for each affected eye/patient at every visit from center inception (1978, 1978, 1984, 2005) until 2010. Remission was defined as inactivity of disease off all suppressive medications at all visits spanning at least three consecutive months or at all visits up to the last visit (to avoid censoring patients stopping follow-up after remission). Factors potentially predictive of remission were assessed using Cox regression models.

RESULTS

During 1,906 years' aggregate follow-up of 832 affected eyes, remission occurred in 214 (170 of 584 patients). Median time-to-remission of scleritis = 7.8 years (95% confidence interval [CI]: 5.7, 9.5). More remissions occurred earlier than later during follow-up. Factors predictive of less scleritis remission included scleritis bilaterality (adjusted hazard ratio [aHR] = 0.46, 95% CI: 0.32-0.65); and diagnosis with any systemic inflammatory disease (aHR = 0.36, 95% CI: 0.23-0.58), or specifically with Rheumatoid Arthritis (aHR = 0.22), or Granulomatosis with Polyangiitis (aHR = 0.08). Statin treatment (aHR = 1.53, 95% CI: 1.03-2.26) within ≤90 days was associated with more remission incidence.

CONCLUSIONS

Our results suggest scleritis remission occurs more slowly in anterior scleritis than in newly diagnosed anterior uveitis or chronic anterior uveitis, suggesting that attempts at tapering suppressive medications is warranted after long intervals of suppression. Remission is less frequently achieved when systemic inflammatory diseases are present. Confirmatory studies of whether adjunctive statin treatment truly can enhance scleritis remission (as suggested here) are needed.

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.

The current status of biological treatment for uveitis

INTRODUCTION

Noninfectious uveitis represents one of the leading causes of blindness in developed Countries, compromising patients' quality of life and social functioning. The main treatment goals are the control of ocular inflammation, to avert and treat sight-threatening complications, thus preserving and/or restoring visual function.

AREAS COVERED

This manuscript deals with systemic therapy with biologic drugs for noninfectious uveitis. An extensive literature search in the MEDLINE database (via PubMed) has been performed up to June 2020. The major classes of biologic molecules employed in ocular inflammatory diseases have been reviewed, focusing on TNF inhibitors, IL-1, IL-6, IL-17, IL-23 inhibitors, interferons, rituximab, and abatacept efficacy and safety. An overview of most recent developments in the field has been provided as well, with reference to the experience with JAK inhibitors and with biosimilar drugs.

EXPERT OPINION

The development of the concept of targeted therapy and the subsequent introduction of biologic molecules in clinical practice have revolutionized the prognosis of uveitis. The target of a rapid and sustained steroid-free remission of ocular inflammation should be pursued for all patients early in the disease course, in order to have a better chance to improve the final visual outcome.

New Potential Weapons for Refractory Scleritis in the Era of Targeted Therapy

OBJECTIVE

To assess the efficacy of biologic drugs, beyond tumor necrosis factor- (TNF-) α inhibitors, in the management of noninfectious refractory scleritis, either idiopathic or associated with systemic immune-mediated disorders. Patients and Methods. This is a retrospective study assessing the efficacy of several biologic agents (rituximab, anakinra, tocilizumab, and abatacept) and the small molecule tofacitinib in the treatment of scleritis through assessment of scleral inflammation and relapses, as well as treatment impact on best-corrected visual acuity (BCVA) and safety profile.

RESULTS

Fourteen patients (19 eyes) were enrolled in the study. Scleritis inflammatory grading significantly improved from baseline to 3 months (p = 0.002) and from baseline to the last follow-up visit (p = 0.002). Scleritis relapses significantly decreased between the 12 months preceding and following biologic therapy (p = 0.007). No differences regarding BCVA were observed (p = 0.67). Regarding adverse events, only one patient developed pneumonia and septic shock under rituximab treatment.

CONCLUSIONS

Our results, though limited to a low number of patients, highlight the effectiveness of different biologic therapies in the treatment of noninfectious refractory scleritis, showing to control scleral inflammation and allowing a significant reduction in the number of relapses.

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.

Biologics for the treatment of noninfectious uveitis: current concepts and emerging therapeutics

PURPOSE OF REVIEW

There is mounting evidence supporting the use of biologic therapeutics for the management of noninfectious uveitis (NIU). This review highlights: biologics with documented efficacy in NIU; agents with ongoing evaluation for efficacy in uveitis; and therapeutics for which investigation for efficacy in NIU is warranted.

RECENT FINDINGS

The tumor necrosis factor-alpha (TNF-α) inhibitor adalimumab has recently gained approval by the Food and Drug Administration for the treatment of noninfectious intermediate, posterior, and panuveitis. There is mounting evidence supporting the use of tocilizumab and rituximab in NIU. There is developing interest in evaluating the interleukin (IL)-23 inhibitors for efficacy in NIU.

SUMMARY

The TNF-α inhibitors adalimumab and infliximab have the greatest body of data supporting their use in NIU. These agents are considered second-line therapy for most forms of NIU but may be considered first-line therapy for uveitis associated with Behçet's disease and juvenile idiopathic arthritis. The B-cell inhibitor rituximab and the IL-6 inhibitor tocilizumab also have documented efficacy in NIU. Tocilizumab and interferon therapy may be particularly efficacious in the management of uveitic macular edema. The IL-23 inhibitors and janus kinase inhibitors are agents whose efficacy in NIU will likely be determined in the near future.

Ocular Manifestations of Rheumatoid Arthritis: Implications of Recent Clinical Trials

While rheumatoid arthritis (RA) typically presents with synovitis of the small and medium joints of the hands, ocular manifestations of the disease are generally overlooked and largely underdiagnosed. These complications usually present in longstanding RA population and occasionally represents the first manifestation of the disease and generally affect the anterior chamber of the eye, leading to keratoconjunctivitis sicca, episcleritis, scleritis, peripheral ulcerative keratitis and anterior uveitis. In this review, we present the current understanding of the pathophysiologic mechanisms for ocular disease in RA, including the role of oxidative stress, cytokine imbalance, chronic inflammation, vascular permeability, immune complex deposition and the role of T-cells as well as the contribution of tear hyperosmolarity among other factors. We also discuss the clinical presentation and diagnosis of each of the ocular disease entities highlighting the latest strategies in the management of this serious disorders that could potentially lead to blindness and the implications of recently completed and ongoing clinical trials in the field. While RA disease control is the cornerstone in the management of RA-associated ocular manifestations, early recognition of ocular pathology with prompt referral to ophthalmology is of paramount importance in order to prevent blindness and improve the quality of life in this patient population.

Targeting Interleukin-23 in the Treatment of Noninfectious Uveitis

The interleukin (IL)-23/IL-17 axis plays a central role in the pathogenesis of immune-mediated diseases such as psoriasis, psoriatic arthritis, Crohn's disease, and uveitis. Therefore, targeting the IL-23/IL-17 axis has become the focus of multiple clinical trials for drug development in patients with autoimmune diseases. We briefly describe the biology of the IL-23/IL-17 axis and its relevance to the pathogenesis of experimental and clinical uveitis, and review the monoclonal antibody therapies targeting this pathway. Finally, 2 ongoing phase 2 trials of the anti-IL-23 biologic therapy ustekinumab (STELARA, Janssen Biotech Inc, Horsham, PA) in patients with noninfectious uveitis are introduced.

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.

WALDENSTRÖM'S MACROGLOBULINEMIA MASQUERADING AS BIRDSHOT CHORIORETINOPATHY

PURPOSE

To describe Waldenström's macroglobulinemia (WM) as a masquerade syndrome.

METHODS

Case report.

RESULTS

A 59-year-old human leukocyte antigen (HLA)-A29-negative white male presented with a 7-year history of floaters, progressive vision loss, and poor contrast sensitivity along with choroidal lesions suggestive of birdshot chorioretinopathy (BCR). Fluorescein angiography, fundus autofluorescence, and indocyanine green angiography showed multiple areas of hyperfluorescence and hypofluorescence. Electroretinography showed reduced cone and rod responses. Comprehensive workup for infectious, paraneoplastic, and other causes including sarcoidosis was negative at the time. The patient was treated with multiple immunomodulatory agents without any significant improvement. Two years after initial presentation, the patient developed normocytic anemia and high levels of inflammatory markers. Further workup yielded a diagnosis of WM. His choroidal lesions were significantly reduced after treatment with rituximab and bendamustine.

CONCLUSION

We report a case of WM masquerading as BCR. Other indolent diseases should be considered in the differential diagnosis for HLA-A29-negative patients presenting with birdshot-like lesions, especially if they are clinically unresponsive to multiple systemic immunosuppressive agents.

Red Eye: A Guide for Non-specialists

BACKGROUND

Red eye can arise as a manifestation of many different systemic and ophthalmological diseases. The physician whom the patient first consults for this problem is often not an ophthalmologist. A correct assessment of the urgency of the situation is vitally important for the planning of further diagnostic evaluation and treatment.

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed in August 2016 as well as on the authors' own clinical and scientific experience.

RESULTS

Primary care physicians typically see 4-10 patients per week who complain of ocular symptoms. Most of them have red eye as the major clinical finding. A detailed history, baseline ophthalmological tests, and accompanying manifestations can narrow down the differential diagnosis. The duration and laterality of symptoms (uni- vs. bilateral) and the intensity of pain are the main criteria allowing the differentiation of non-critical changes that can be cared for by a general practitioner from diseases calling for elective referral to an ophthalmologist and eye emergencies requiring urgent ophthalmic surgery.

CONCLUSION

The differential diagnosis of red eye can be narrowed down rapidly with simple baseline tests and targeted questioning. Patients with ocular emergencies should be referred to an ophthalmologist at once, as should all patients whose diagnosis is in doubt.

Management of Uveitis and Scleritis in Necrobiotic Xanthogranuloma

Necrobiotic xanthogranuloma (NXG) is a chronic, progressive non-Langerhans histiocytic granulomatous disease. While case reports describing periorbital involvement of NXG are frequent, only a few case reports describing ocular involvement, such as scleritis and uveitis, exist. Herein, we present a case presenting initially as bilateral anterior and posterior scleritis, as well as a chronic bilateral granulomatous panuveitis, and discuss the immunosuppressant options that should be considered for this disease with protean manifestations.