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

Scleromalacia perforans as an early manifestation of late-onset rheumatoid arthritis: a case-based review

Rheumatoid arthritis is a chronic autoimmune disease that can affect different organs beyond the joints. Ocular involvement includes keratoconjunctivitis sicca, peripheral ulcerative keratitis (PUK), episcleritis, scleritis, anterior uveitis, and corneal impairment. The most severe form of scleritis, scleromalacia perforans, is an aggressive ophthalmic manifestation that can potentially lead to blindness, usually occurring in late stages of disease. We report a case of an elderly woman in which this severe ocular manifestation occurred early on disease onset, differing from most of the previously reported cases of scleromalacia perforans. Ocular symptoms started concomitantly with the polyarthritis and other extra-articular manifestations, including rheumatoid nodules and vasculitic skin lesions. Ocular disease progressed due to patient's loss to follow-up, requiring pulse therapy with methylprednisolone. However, despite treatment, right eye enucleation was required due to melting of the corneal patch with uveal exposition. The patient was then treated with rituximab with improvement of systemic disease. The present case reinforces that, although rare, this complication is severe and must be promptly diagnosed and aggressively treated to improve prognosis of ocular and systemic RA.

Felty Syndrome in a Patient Presenting With Bilateral Scleritis and Multiple Autoimmune Syndrome: A Case Report

Autoimmune diseases can result in additional symptoms and complications impacting various organ systems beyond the joints. These can affect the eyes, skin, respiratory, cardiac, and renal systems. Recognizing and understanding these diverse manifestations, such as the severe eye issues seen in rheumatoid arthritis (RA) and the potentially life-threatening Felty syndrome, is crucial for clinicians to promptly identify and treat these conditions effectively. In this case presentation, we report on a patient admitted for bilateral scleritis, which was found to be secondary to multiple autoimmune syndrome type 3. During the patient's hospital stay, Felty syndrome was incidentally diagnosed due to the observed combination of RA, splenomegaly, and absolute neutropenia. Prompt recognition of this condition allowed the patient to receive appropriate care, including oral steroids, hydroxychloroquine, and methotrexate, decreasing the risk of severe complications.

Ophthalmological Manifestations in Inflammatory Bowel Diseases: Keep an Eye on It

BACKGROUND AND AIMS

Inflammatory bowel diseases (IBD) are multifactorial chronic inflammatory disorders affecting the gastrointestinal tract. However, a broad spectrum of extraintestinal manifestations (EIMs) is associated with IBD, affecting several organs and systems, such as the skin, musculoskeletal and hepatobiliary systems, and, not least, the eye. Approximately 10% of IBD patients can develop ocular EIMs (O-EIMs) with a higher prevalence in Crohn's disease (CD). Eye-redness, photophobia, pain, and blurred vision are the common symptoms, with a wide rate of severity and clinical impact on the quality of life. This narrative review aims to summarize the prevalence, pathogenesis, and current evidence-based management of O-EIMs, underlying the importance of a holistic approach and specialties collaboration for a prompt diagnosis and treatment.

METHODS

PubMed was searched up to December 2023 to identify relevant studies investigating the pathogenesis, epidemiology, and treatment of O-EIMs in IBD patients.

RESULTS

The mechanisms underlying O-EIMs are partially unknown, encompassing immune dysregulation, shared antigens between the eye and the gut, genetic predisposition, and systemic inflammation driven by high levels of interleukins and cytokines in IBD patients. The complexity of O-EIMs' pathogenesis reflects in the management of these conditions, varying from topical and systemic steroids to immunomodulatory molecules and biologic therapy, such as anti-tumor necrosis factor (TNF)-alpha. A multidisciplinary approach is the backbone of the management of O-EIMs.

Surgical induced necrotizing scleritis following intraocular lens replacement

PURPOSE

To report a surgical-induced necrotizing scleritis, as well as its medical and surgical management.

METHODS

Case-report.

RESULTS

An 88 year-old patient with a three-day severe single-left-eye ocular pain. One-time surgery involving PPV with removal of dislocated intraocular lens and secondary implantation of iris-claw Artisan® lens was performed 6 months earlier. Visual acuity of 20/100. Slit-lamp examination revealed a 5 × 2 mm non-suppurative superior scleral defect. Empirical topical antibiotic treatment with dexamethasone, as well as oral doxycycline was started. Infectious and autoimmune diseases were ruled out. Non-infectious scleritis treatment was conducted with intravenous Methylprednisolone 3 day pulses, followed by weekly tapered Prednisone and intramuscular Methotrexate. However, 1 month after the diagnosis, the defect was worsened; hence, a heterologous scleral patch graft was performed and, days after the intervention, Adalimumab was initiated. To date, 6 months later, remains with proper scleral patch, a diary low-dose Prednisone, and spacing Adalimumab treatment.

CONCLUSION

Surgery-induced necrotizing scleritis is a severe condition that compromise the ocular and visual integrity. Proper diagnosis, as well as early treatment is required to achieve remission, prevent relapses, and avoid structural complications. In refractory cases, anti-TNF-α immunotherapy associated with surgical tectonic graft interventions can achieve promising results.

[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.

Spectrum of and Factors Associated with Eye Disorders among Rheumatoid Arthritis Patients Attending Tertiary Hospital in Uganda

Background

Ocular morbidities associated with rheumatoid arthritis (RA) have not received much attention in Africa, particularly in sub-Saharan Africa. They are among the commonest (40%) extra-articular organ involvement in RA. If undiagnosed, there is a potential risk of them causing visual impairment or blindness. There is no documented study in Uganda on the magnitude of eye disorders among RA patients.

Aim

To determine the spectrum of eye disorders and associated factors among patients with RA attending Mulago National Referral Hospital.

Methods

A hospital based cross-sectional study was conducted among adults with RA attending the rheumatology clinic between July 2021 and September 2021. Clinical and sociodemographic data were collected, and ophthalmologic examinations were performed on all consenting participants. Modified Poisson regression with robust standard error was used to determine factors associated with eye disorders.

Results

Overall, 105 patients with RA were enrolled, of which, 53 (50.5%) had eye disorders. The commonest disorder (54.7%, n=29) was dry-eye syndrome. Factors that were significantly associated with eye disorders were age 36-55 years (aPR 1.56, p=0.015), duration of RA >5 years (aPR 1.81, p=0.001), use of hydroxychloroquine >5 years (aPR 1.77, p=0.041), dose of oral steroids >10 mg/day (aPR 1.49, p=0.034), and history of both diabetes and hypertension (aPR 1.87, p=0.014).

Conclusion

The prevalence of eye disorders among patients with RA was high, with the commonest being dry-eye syndrome. We recommend that ocular examinations be performed on every patient at the time of RA diagnosis for early detection of eye disorders.

Episcleritis; and posterior uveitis misdiagnosed as orbital cellulitis in a child patient with Behçet's disease

Behçet's disease is a chronic multisystem vasculitis that presented with several manifestations. Episcleritis is a benign inflammation of the episcleral tissue and is rarely reported in Behçet's disease. We reported an 11-year-old girl who was admitted due to pain and swelling around the left eye with initial diagnosis of preseptal cellulitis. The patient had a history of recurrent oral aphthous ulcers and genital ulcers. Episcleritis and posterior uveitis were reported in ophthalmic examination and ultrasonography. Pathergy skin test and human leukocyte antigens (HLA) B5 and HLA-B51 were positive, consistent with the diagnosis of Behcet's disease. This case report emphasizes that various pathological causes may cause episcleritis and uveitis in children, one of which is rheumatic diseases, that should always be considered.

Connective tissue disorders and eye: A review and recent updates

Collagen vascular disorders (CVDs), also known as connective tissue diseases (CTDs), are a heterogeneous group of entities that affect the connective tissues and are capable of causing end-organ damage to multiple systems, primarily cardiopulmonary and musculoskeletal. However, the occurrence and severity are highly variable among patients. Ocular involvement occurs in a significant number of these disorders and may precede the onset of other extraocular features, thereby serving as an important marker in the diagnosis of these diseases. A timely and accurate diagnosis enables the management of complications. CTDs are primarily immune-mediated inflammatory diseases; however, classifications have encompassed heritable disorders affecting collagen-containing structures and disorders of vascular development. A review of literature published until 25 January 2022 and collected from various databases using the relevant keywords was conducted. All publications (original articles, review articles, as well as case reports) describing the ocular features in CTDs were studied in detail. The objective of this review is to recognize the common ophthalmic presentations of various autoimmune and heritable CTDs, distinguish them from overlapping diseases, elaborate on the prognosis and management of these varied eye presentations, and deliberate on their impact on other ophthalmic surgeries.

Inflammatory eye disease for rheumatologists

PURPOSE OF REVIEW

This review provides a framework for understanding inflammatory eye disease diagnosis, differential diagnosis, and management for rheumatologists. Uveitis, scleritis, episcleritis, peripheral ulcerative keratitis, and orbital inflammation are all discussed. The goal is to facilitate the development of approaches to inflammatory eye diseases that will help rheumatologists co-manage these patients with eye care providers specializing in ocular inflammation.

RECENT FINDINGS

In recent years, studies have aimed to advance biologic treatments and define standard-of-care therapy. Inflammatory eye diseases are highly heterogeneous and often rare, which poses significant challenges to their research and the interpretation of existing data. To date, glucocorticoids, mycophenolate, methotrexate, and TNF inhibitors remain the mainstay of treatment options for many of these diseases.

SUMMARY

Patients with inflammatory eye diseases require multidisciplinary care for best outcomes, frequently including rheumatologists. Understanding the differentials, diagnostics, and treatment are essential to preserving vision in these patients. The diverse nature of the disease processes within this field requires focusing on specific disease phenotypes and endotypes in research and clinical practice.

Identifying TNF and IL6 as potential hub genes and targeted drugs associated with scleritis: A bio-informative report

Background

Scleritis is a serious inflammatory eye disease that can lead to blindness. The etiology and pathogenesis of scleritis remain unclear, and increasing evidence indicates that some specific genes and proteins are involved. This study aimed to identify pivotal genes and drug targets for scleritis, thus providing new directions for the treatment of this disease.

Methods

We screened candidate genes and proteins associated with scleritis by text-mining the PubMed database using Python, and assessed their functions by using the DAVID database. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were used to identify the functional enrichment of these genes and proteins. Then, the hub genes were identified with CytoHubba and assessed by protein-protein interaction (PPI) network analysis. And the serum from patients with active scleritis and healthy subjects were used for the validation of hub genes. Finally, the DGIdb database was used to predict targeted drugs for the hub genes for treating scleritis.

Results

A total of 56 genes and proteins were found to be linked to scleritis, and 65 significantly altered pathways were identified in the KEGG analysis (FDR < 0.05). Most of the top five pathways involved the categories “Rheumatoid arthritis,” “Inflammatory bowel disease”, “Type I diabetes mellitus,” and “Graft-versus-host disease”. TNF and IL6 were considered to be the top 2 hub genes through CytoHubba. Based on our serum samples, hub genes are expressed at high levels in active scleritis. Five scleritis-targeting drugs were found among 88 identified drugs.

Conclusions

This study provides key genes and drug targets related to scleritis through bioinformatics analysis. TNF and IL6 are considered key mediators and possible drug targets of scleritis. Five drug candidates may play an important role in the diagnosis and treatment of scleritis in the future, which is worthy of the further experimental and clinical study.

Signaling pathways in rheumatoid arthritis: implications for targeted therapy

Rheumatoid arthritis (RA) is an incurable systemic autoimmune disease. Disease progression leads to joint deformity and associated loss of function, which significantly impacts the quality of life for sufferers and adds to losses in the labor force. In the past few decades, RA has attracted increased attention from researchers, the abnormal signaling pathways in RA are a very important research field in the diagnosis and treatment of RA, which provides important evidence for understanding this complex disease and developing novel RA-linked intervention targets. The current review intends to provide a comprehensive overview of RA, including a general introduction to the disease, historical events, epidemiology, risk factors, and pathological process, highlight the primary research progress of the disease and various signaling pathways and molecular mechanisms, including genetic factors, epigenetic factors, summarize the most recent developments in identifying novel signaling pathways in RA and new inhibitors for treating RA. therapeutic interventions including approved drugs, clinical drugs, pre-clinical drugs, and cutting-edge therapeutic technologies. These developments will hopefully drive progress in new strategically targeted therapies and hope to provide novel ideas for RA treatment options in the future.

Novel pentacyclic derivatives and benzylidenes of the progesterone series cause anti-estrogenic and antiproliferative effects and induce apoptosis in breast cancer cells

The promising antitumor effects of progesterone derivatives have been identified in many studies. However, the specific mechanism of action of this class of compounds has not been fully described. Therefore, in this study, we investigated the antiproliferative and (anti)estrogenic activities of novel pentacyclic derivatives and benzylidenes of the progesterone series. The antiproliferative effects of the compounds were evaluated on hormone-dependent MCF7 breast cancer cells using the MTT test. Estrogen receptor α (ERα) activity was assessed by a luciferase-based reporter assay. Immunoblotting was used to evaluate the expression of signaling proteins. All benzylidenes demonstrated inhibitory effects with IC₅₀ values below 10 µM, whereas pentacyclic derivatives were less active. These patterns may be associated with the lability of the geometry of benzylidene molecules, which contributes to an increase in the affinity of interaction with the receptor. The selected compounds showed significant anti-estrogenic potency. Benzylidene 1d ((8 S,9 S,10R,13 S,14 S,17 S)-17-[(2E)-3-(4-fluorophenyl)prop-2-enoyl]-10,13-dimethyl-1,2,6,7,8,9,11,12,14,15-decahydrocyclopenta[a]phenanthren-3-one) was the most active in antiproliferative and anti-estrogenic assays. Apoptosis induced by compound 1d was accompanied by decreases in CDK4, ERα, and Cyclin D1 expression. Compounds 1d and 3d were characterized by high inhibitory potency against resistant breast cancer cells. Apoptosis induced by the leader compounds was confirmed by PARP cleavage and flow cytometry analysis. Compound 3d caused cell arrest in the G2/M phase. Further analysis of novel derivatives of the progesterone series is of great importance for medicinal chemistry, drug design, and oncology.

A rare case of scleritis and multiple rheumatoid pulmonary nodules associated with seronegative rheumatoid arthritis

Seronegative rheumatoid arthritis (RA) is less likely to have extra-articular manifestations than seropositive RA. An 80-year-old man with polyarthritis was diagnosed with seronegative RA in which rheumatoid factors and anti-cyclic citrullinated peptides were not detected. He had multiple pulmonary nodules that diminished in size following treatment for RA, leading to the diagnosis of pulmonary rheumatoid nodules. During his treatment course, he developed scleritis, which could have resulted in blindness. As oral steroids did not improve his condition, topical steroid injections were administered, and his symptoms gradually improved. Here, we present a case of seronegative RA with an unusual combination of extra-articular manifestations: rheumatoid pulmonary nodules and scleritis.

Ocular manifestations of rheumatoid arthritis

PURPOSE OF REVIEW

This article summarizes the pathophysiology of rheumatoid arthritis and common ocular manifestations that it is associated with: keratoconjunctivitis sicca, episcleritis, scleritis, and peripheral ulcerative keratitis.

RECENT FINDINGS

Newer biologic agents are being used to effectively treat rheumatoid arthritis and its ocular manifestations.

SUMMARY

The eye is a frequent extra-articular site of inflammation in patients with rheumatoid arthritis. Ocular involvement can range from more benign conditions such as keratoconjunctivitis sicca and episcleritis, to potentially vision and globe-threatening diseases like scleritis and peripheral ulcerative keratitis. Clinicians should be aware of these ophthalmic manifestations and the various treatment options that are available. Coordination between ophthalmology and rheumatology is helpful in the treatment of these patients.

Comparison of Intestinal Microbes in Noninfectious Anterior Scleritis Patients With and Without Rheumatoid Arthritis

We compared intestinal microbes in anterior noninfectious scleritis patients with and without rheumatoid arthritis. Active noninfectious anterior scleritis patients without other immune diseases (G group, 16 patients) or with active rheumatoid arthritis (GY group, seven patients) were included in this study. Eight age- and sex-matched healthy subjects served as controls (N group). DNA was extracted from fecal samples. The V3-V4 16S rDNA region was amplified and sequenced by high-throughput 16S rDNA analysis, and microbial contents were determined. A significant decrease in species richness in the GY group was revealed by α- and β-diversity analyses (p = 0.02 and p = 0.004, respectively). At the genus level, 14 enriched and 10 decreased microbes in the G group and 13 enriched and 18 decreased microbes in the GY group were identified. Among them, four microbes were enriched in both the G and GY groups, including Turicibacter, Romboutsia, Atopobium, and Coprobacillus. Although two microbes (Lachnospiraceae_ND3007_group and Eggerthella) exhibited similar tendencies in the G and GY groups, changes in these microbes were more significant in the GY group (p < 0.05). Interaction analysis showed that Intestinibacter, Romboutsia, and Turicibacter, which were enriched in both the G and GY groups, correlated positively with each other. In addition, nine microbes were decreased in the GY group, which demonstrates a potential protective role for these microbes in the pathogenesis of scleritis via interactions with each other.