Scleritis in Emergency Medicine Medication

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.^[16]

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.

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.^[17] 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.^[15]

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.

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.

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.

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.