Scleritis Treatment & Management

  • Author: Maite Sainz de la Maza, MD, PhD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 18, 2010
 

Medical Care

Treatment of scleritis almost always requires systemic therapy. Patients with an associated disease, such as rosacea, gout, atopy, or infection, need specific treatment.

  • Treatment of noninfectious scleritis: Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or immunomodulatory drugs are indicated. Topical therapy is routinely insufficient. This treatment must be individualized for the severity of the scleritis, response to treatment, adverse effects, and presence of the associated disease.
    • Diffuse scleritis or nodular scleritis
      • The initial therapy consists of an NSAID; in case of therapeutic failure, 2 different NSAIDs should be tried in succession with the first drug. In high-risk patients, consider appropriate gastrointestinal protection with misoprostol or omeprazole.
      • If NSAIDs are not effective or have untoward complications, oral corticosteroids can be substituted. Remission may be maintained with continued NSAIDs.
      • Periorbital and subconjunctival steroid injections have been reported to be efficacious as adjunctive therapy. Caution should be observed.[6]
      • In case of therapeutic failure of corticosteroids, immunosuppressive drugs should be added or substituted. Methotrexate (MTX) can be the first choice, but azathioprine, mycophenolate mofetil, cyclophosphamide, or cyclosporine may be helpful.[7, 8, 9] Cyclophosphamide should be the first choice in treating patients with associated potentially lethal vasculitic diseases, such as Wegener granulomatosis or polyarteritis nodosa.
      • In case of therapeutic failure, other immunomodulatory drugs, such as infliximab or adalimumab, may be effective.[10, 11, 12, 13] Other alternatives are daclizumab and rituximab, although further investigation is warranted.[14, 15, 16]
    • Necrotizing scleritis
      • The initial therapy consists of immunosuppressive drugs that are supplemented with corticosteroids during the first month; the latter is tapered slowly, if possible. Cyclophosphamide should be the first choice in treating patients with an underlying systemic vasculitis such as Wegener granulomatosis or polyarteritis nodosa
      • In case of therapeutic failure, other immunomodulatory drugs, such as infliximab or adalimumab, may be effective. Other alternatives are daclizumab and rituximab, although their efficacy awaits further study.[16, 17]
      • Periocular steroid injections should not be applied in cases of necrotizing scleritis or peripheral ulcerative keratitis. Some authors believe that depot steroids actually may exacerbate necrotizing disease.
      • Pulse intravenous cyclophosphamide with or without pulse intravenous corticosteroids may be required for urgent cases and may be followed by maintenance therapy.
  • Treatment of infectious scleritis: Systemic treatment with or without topical antimicrobial therapy always is required. Differentiating infectious scleritis from noninfectious scleritis is important because corticosteroid therapy and immunosuppressive therapy (often used in noninfectious autoimmune scleritis) are contraindicated in active infections.
Next

Surgical Care

  • Tectonic surgical procedures rarely may be required to preserve the integrity of the globe.
    • Scleral grafts are fresh sclera or glycerin-preserved sclera that is available through eye banks. Grafts may be performed in cases of pending perforation during the time before the effects of systemic immunosuppressive agents manifest.[18]
    • Corneal tissue may be used for associated corneal disease.
Previous
Next

Consultations

  • Consultation with a rheumatologist or internal medicine specialist for associated disease
  • Consultation with a hematologist, oncologist, or internal medicine specialist for immunosuppressive therapy
Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Maite Sainz de la Maza, MD, PhD  Associate Professor, Division of Ocular Immunology and Uveitis, Department of Ophthalmology, Hospital Clinico y Provincial, Barcelona, Spain

Maite Sainz de la Maza, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology and American Uveitis Society

Disclosure: Nothing to disclose.

Specialty Editor Board

John D Sheppard Jr, MD, MMSc  Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Program Director, Ophthalmology Residency Training, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, American Uveitis Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Sainz de la Maza M, Foster CS, Jabbur NS. Scleritis associated with rheumatoid arthritis and with other systemic immune-mediated diseases. Ophthalmology. Jul 1994;101(7):1281-6; discussion 1287-8. [Medline].

  2. Sainz de la Maza M, Foster CS, Jabbur NS. Scleritis associated with systemic vasculitic diseases. Ophthalmology. Apr 1995;102(4):687-92. [Medline].

  3. French DD, Margo CE. Postmarketing surveillance rates of uveitis and scleritis with bisphosphonates among a national veteran cohort. Retina. Jun 2008;28(6):889-93. [Medline].

  4. [Guideline] Zimmerman RD, Seidenwurm DJ, Davis PC, et al. ACR Appropriateness Criteria. Orbits, vision, and visual loss. National Guideline Clearinghouse. 2006.

  5. Nieuwenhuizen J, Watson PG, Emmanouilidis-van der Spek K, Keunen JE, Jager MJ. The value of combining anterior segment fluorescein angiography with indocyanine green angiography in scleral inflammation. Ophthalmology. Aug 2003;110(8):1653-66. [Medline].

  6. Hakin KN, Ham J, Lightman SL. Use of orbital floor steroids in the management of patients with uniocular non-necrotising scleritis. Br J Ophthalmol. Jun 1991;75(6):337-9. [Medline].

  7. Galor A, Jabs DA, Leder HA, Kedhar SR, Dunn JP, Peters GB 3rd. Comparison of antimetabolite drugs as corticosteroid-sparing therapy for noninfectious ocular inflammation. Ophthalmology. Oct 2008;115(10):1826-32. [Medline].

  8. Sobrin L, Christen W, Foster CS. Mycophenolate mofetil after methotrexate failure or intolerance in the treatment of scleritis and uveitis. Ophthalmology. Aug 2008;115(8):1416-21, 1421.e1. [Medline].

  9. Wakefield D, McCluskey P. Cyclosporin therapy for severe scleritis. Br J Ophthalmol. Sep 1989;73(9):743-6. [Medline].

  10. Cazabon S, Over K, Butcher J. The successful use of infliximab in resistant relapsing polychondritis and associated scleritis. Eye (Lond). Feb 2005;19(2):222-4. [Medline].

  11. Huynh N, Cervantes-Castaneda RA, Bhat P, Gallagher MJ, Foster CS. Biologic response modifier therapy for psoriatic ocular inflammatory disease. Ocul Immunol Inflamm. May-Jun 2008;16(3):89-93. [Medline].

  12. Murphy CC, Ayliffe WH, Booth A, Makanjuola D, Andrews PA, Jayne D. Tumor necrosis factor alpha blockade with infliximab for refractory uveitis and scleritis. Ophthalmology. Feb 2004;111(2):352-6. [Medline].

  13. Sobrin L, Kim EC, Christen W, Papadaki T, Letko E, Foster CS. Infliximab therapy for the treatment of refractory ocular inflammatory disease. Arch Ophthalmol. Jul 2007;125(7):895-900. [Medline].

  14. Ahmadi-Simab K, Lamprecht P, Nolle B, Ai M, Gross WL. Successful treatment of refractory anterior scleritis in primary Sjogren's syndrome with rituximab. Ann Rheum Dis. Jul 2005;64(7):1087-8. [Medline].

  15. Cheung CM, Murray PI, Savage CO. Successful treatment of Wegener's granulomatosis associated scleritis with rituximab. Br J Ophthalmol. Nov 2005;89(11):1542. [Medline].

  16. Papaliodis GN, Chu D, Foster CS. Treatment of ocular inflammatory disorders with daclizumab. Ophthalmology. Apr 2003;110(4):786-9. [Medline].

  17. Onal S, Kazokoglu H, Koc A, Yavuz S. Rituximab for remission induction in a patient with relapsing necrotizing scleritis associated with limited Wegener´s granulomatosis. Ocul Immunol Inflamm. Sep-Oct 2008;16(5):230-232.

  18. Sainz de la Maza M, Tauber J, Foster CS. Scleral grafting for necrotizing scleritis. Ophthalmology. Mar 1989;96(3):306-10. [Medline].

  19. Fong LP, Sainz de la Maza M, Rice BA, Kupferman AE, Foster CS. Immunopathology of scleritis. Ophthalmology. Apr 1991;98(4):472-9. [Medline].

  20. Sainz de la Maza M, Jabbur NS, Foster CS. An analysis of therapeutic decision for scleritis. Ophthalmology. Sep 1993;100(9):1372-6. [Medline].

  21. Sainz de la Maza M, Jabbur NS, Foster CS. Severity of scleritis and episcleritis. Ophthalmology. Feb 1994;101(2):389-96. [Medline].

  22. Tuft SJ, Watson PG. Progression of scleral disease. Ophthalmology. Apr 1991;98(4):467-71. [Medline].

  23. Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol. Mar 1976;60(3):163-91. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.