Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Scleritis in Emergency Medicine Medication

  • Author: Theodore J Gaeta, DO, MPH, FACEP; Chief Editor: Robert E O'Connor, MD, MPH  more...
 
Updated: Dec 29, 2015
 

Medication Summary

Therapeutic goals for scleritis are familiar to any emergency practitioner: relieve the patient’s pain and initiate therapy that will positively alter the course of the disease.[20]

From the patient's perspective, pain cessation may be the most important action taken by the emergency practitioner. Outcome will depend on the patient's response to immunosuppressive therapy.[21]

Narcotics and systemic NSAIDs may render temporary pain relief and can be started in the ED.

NSAIDs are generally found to be effective in approximately one third of patients with diffuse anterior scleritis and two thirds of patients with nodular anterior scleritis.[22, 23] NSAIDs have also been found to be helpful in patients with idiopathic posterior scleritis.

Initiation of immunosuppressive therapy may require coordination with an internist and/or rheumatologist.

Topical steroids have a high failure rate but should be discussed with the practitioner who will provide follow-up care.[19]

Subconjunctival steroid injections for non-necrotizing scleritis remain controversial. Localized steroid injections may lead to increased intraocular pressure, scleral melting, or globe perforation/scleral rupture.

Surgical management is generally not required except in rare cases of necrotizing scleritis.

Next

Nonsteroidal anti-inflammatory drugs

Class Summary

These agents are used to decrease pain and inflammation. NSAIDs are thought to act by inhibiting prostaglandin synthesis, interfering with migration of leukocytes, and inhibiting phosphodiesterase.

Indomethacin (Indocin)

 

Often considered the DOC. Indomethacin is rapidly absorbed. Metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation.

Diflunisal (Dolobid)

 

Nonsteroidal salicylic acid derivative that acts peripherally as an analgesic. Has antipyretic and anti-inflammatory effects; however, differs chemically from aspirin and is not metabolized to salicylic acid. It is a prostaglandin-synthetase inhibitor.

Naproxen (Naprelan, Anaprox, Aleve, Naprosyn)

 

Used for relief of mild-to-moderate pain. It inhibits inflammatory reactions and pain by decreasing the activity of the enzyme cyclooxygenase, resulting in a decrease of prostaglandin synthesis.

Naproxen is rapidly absorbed and has a half-life of 12-15 h. It is highly protein bound.

Ibuprofen (Motrin, Ibuprin, Advil)

 

Usually the DOC for treatment of mild- to- moderate pain, if no contraindications exist. Inhibits inflammatory reactions and pain, probably by decreasing activity of the enzyme cyclooxygenase, which results in prostaglandin synthesis.

Highly protein-bound drug that is readily absorbed orally. The half-life is short (1.8-2.6 h).

Sulindac (Clinoril)

 

Decreases activity of cyclooxygenase and, in turn, inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators.

Piroxicam (Feldene)

 

Chemically different from other NSAIDs. Extensively bound to plasma proteins. Decreases activity of cyclooxygenase and, in turn, inhibits prostaglandin synthesis. These effects decrease formation of inflammatory mediators.

Previous
Next

Immunosuppressive agents

Class Summary

These agents are used in severe (necrotizing scleritis) and resistant forms of the disease. Only an ophthalmologist experienced with the medication should prescribe these drugs.

Methotrexate (Folex, Rheumatex)

 

Mechanism of action in treatment of inflammatory reactions is unknown. May affect immune function and usually ameliorates symptoms of inflammation (eg, pain, swelling, stiffness).

Cyclophosphamide (Cytoxan, Neosar)

 

Chemically related to nitrogen mustards. As it is an alkylating agent, mechanism of action of active metabolites may involve cross-linking of the DNA, which may interfere with growth of normal and neoplastic cells.

Azathioprine (Imuran)

 

Inhibits mitosis and cellular metabolism by antagonizing purine metabolism and inhibiting synthesis of DNA, RNA, and proteins.

Cyclosporine (Sandimmune, Neoral)

 

Cyclic polypeptide that suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions, such as delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft versus host disease for a variety of organs.

For children and adults, dosing should be based on ideal body weight.

Previous
Next

Glucocorticoids

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli and are useful in the treatment of recurrent scleritis.

Methylprednisolone (Depo-Medrol, Solu-Medrol, Medrol)

 

Administered IM or IV. Usually used in addition with other immunosuppressive agents.

Prednisone (Deltasone, Orasone, Sterapred)

 

Used to treat inflammatory and allergic reactions. By reversing increased capillary permeability and suppressing PMN activity, may decrease inflammation.

Previous
 
 
Contributor Information and Disclosures
Author

Theodore J Gaeta, DO, MPH, FACEP Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, Society for Academic Emergency Medicine, Council of Emergency Medicine Residency Directors, Clerkship Directors in Emergency Medicine, Alliance for Clinical Education

Disclosure: Nothing to disclose.

Coauthor(s)

Diana Valcich, MD Attending Physician, Department of Emergency Medicine, North Shore LIJ Hospital System

Diana Valcich, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Gino A Farina, MD, FACEP, FAAEM Professor of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine at Hofstra University; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Association for Physician Leadership, American Heart Association, Medical Society of Delaware, Society for Academic Emergency Medicine, Wilderness Medical Society, American Medical Association, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Jerome FX Naradzay, MD, Loice Swisher, MD, and Jonathan Adler, MD, to the development and writing of this article.

References
  1. Okhravi N, Odufuwa B, McCluskey P, Lightman S. Scleritis. Surv Ophthalmol. 2005 Jul-Aug. 50(4):351-63. [Medline].

  2. Wirbelauer C. Management of the red eye for the primary care physician. Am J Med. 2006 Apr. 119(4):302-6. [Medline]. [Full Text].

  3. Welch JF, Dickie AK. Red Alert: diagnosis and management of the acute red eye. J R Nav Med Serv. 2014. 100 (1):42-6. [Medline].

  4. Ashok D, Ayliffe WH, Kiely PD. Necrotizing scleritis associated with rheumatoid arthritis: long-term remission with high-dose infliximab therapy. Rheumatology (Oxford). 2005 Jul. 44(7):950-1. [Medline].

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

  6. Rossiter-Thornton M, Rossiter-Thornton L, Ghabrial R, Azar DA. Posterior scleritis mimicking orbital cellulitis. Med J Aust. 2010 Sep 6. 193(5):305-6. [Medline].

  7. Legmann A, Foster CS. Noninfectious necrotizing scleritis. Int Ophthalmol Clin. 1996 Winter. 36(1):73-80. [Medline].

  8. Bonfioli AA, Orefice F. Toxoplasmosis. Semin Ophthalmol. 2005 Jul-Sep. 20(3):129-41. [Medline].

  9. Burton BJ, Cunningham ET Jr, Cree IA, Pavesio CE. Eye involvement mimicking scleritis in a patient with chronic lymphocytic leukaemia. Br J Ophthalmol. 2005 Jun. 89(6):775-6. [Medline].

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

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

  12. Smith JR, Mackensen F, Rosenbaum JT. Therapy insight: scleritis and its relationship to systemic autoimmune disease. Nat Clin Pract Rheumatol. 2007 Apr. 3(4):219-26. [Medline]. [Full Text].

  13. Wakefield D, Di Girolamo N, Thurau S, Wildner G, McCluskey P. Scleritis: challenges in immunopathogenesis and treatment. Discov Med. 2013 Oct. 16(88):153-7. [Medline].

  14. Leung S, Ashar BH, Miller RG. Bisphosphonate-associated scleritis: a case report and review. South Med J. 2005 Jul. 98(7):733-5. [Medline].

  15. Thill M, Richard G. Giant pigment epithelial tear and retinal detachment in a patient with scleritis. Retina. 2005 Jul-Aug. 25(5):667-8. [Medline].

  16. Gonzalez-Gonzalez LA, Molina-Prat N, Doctor P, Tauber J, Sainz de la Maza M, Foster CS. Clinical Features and Presentation of Posterior Scleritis: A Report of 31 Cases. Ocul Immunol Inflamm. 2013 Oct 16. [Medline].

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

  18. Lee SB, Kim KS, Lee WK, Kim YJ, Kang MW. Ocular syphilis characterised by severe scleritis in a patient infected with HIV. Lancet Infect Dis. 2013 Nov. 13(11):994. [Medline].

  19. McMullen M, Kovarik G, Hodge WG. Use of topical steroid therapy in the management of nonnecrotizing anterior scleritis. Can J Ophthalmol. 1999 Jun. 34(4):217-21. [Medline].

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

  21. Jeon HS, Hyon JY, Kim MK, Chung TY, Yoon KC, Kim JY, et al. Efficacy and safety of immunosuppressive agents in the treatment of necrotising scleritis: a retrospective, multicentre study in Korea. Br J Ophthalmol. 2015 Nov 23. [Medline].

  22. Bauer AM, Fiehn C, Becker MD. Celecoxib, a selective inhibitor of cyclooxygenase 2 for therapy of diffuse anterior scleritis. Am J Ophthalmol. 2005 Jun. 139(6):1086-9. [Medline].

  23. Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA, Doctor PP, Tauber J, Foster CS. Scleritis therapy. Ophthalmology. 2012 Jan. 119(1):51-8. [Medline].

  24. Dean WH, Turner SA, McNaught AI. Secondary glaucoma due to chronic scleritis: trabeculectomy in scleromalacia: a case report. Eye (Lond). 2013 Nov 15. [Medline].

  25. Levison AL, Lowder CY, Baynes KM, Kaiser PK, Srivastava SK. Anterior segment spectral domain optical coherence tomography imaging of patients with anterior scleritis. Int Ophthalmol. 2015 Nov 23. [Medline].

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

  27. Boonman ZF, de Keizer RJ, Watson PG. Smoking delays the response to treatment in episcleritis and scleritis. Eye. 2005 Sep. 19(9):949-55. [Medline].

  28. Deokule S, Saeed T, Murray PI. Deep intramuscular methylprednisolone treatment of recurrent scleritis. Ocul Immunol Inflamm. 2005 Feb. 13(1):67-71. [Medline].

  29. Fahim K, Houghton O, Dastjerdi M, Mian SI. Posterior scleritis secondary to Pseudomonas aeruginosa keratitis. Cornea. 2005 Oct. 24(7):879-81. [Medline].

  30. McCluskey P, Wakefield D. Intravenous pulse methylprednisolone in scleritis. Arch Ophthalmol. 1987 Jun. 105(6):793-7. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.