Medication Summary
Nonsteroidal anti-inflammatory drugs (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. [34, 35] NSAIDs have also been found to be helpful in patients with idiopathic posterior scleritis.
Topical steroids (eg, prednisolone acetate 1.0%) can be used in mild cases. [1] They have a high failure rate but should be discussed with the practitioner who will provide follow-up care. [33]
Systemic steroids are second-line treatments prescribed when NSAIDs fail. In noninfectious scleritis, methotrexate appears to be effective as a steroid-sparing agent and for providing long-term control of inflammation. [36] Similarly, rituximab has been found effective for noninfectious scleritis in case reports, a few small case series, and a randomized trial. [37]
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.
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.
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.
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.
Corticosteroids, Ophthalmic
Class Summary
Ocular corticosteroids, anti-inflammatory agents; bacterial and viral infections require concomitant antibacterial and antiviral coverage, respectively
Prednisolone ophthalmic (Econopred Plus, Inflamase Forte, Inflamase Mild)
Dosage for ophthalmic inflammatory conditions is 1-2 gtt of 1% solution BID-QID (may be more frequent during initial 24-48 hr).
Antineoplastics, Anti-CD20 Monoclonal Antibodies
Rituximab (Rituximab-arrx, Riabni, Rituxan)
Rituximab is a humanized monoclonal antibody that binds to CD20 antigen. It is approved for use in rheumatoid arthritis and granulomatosis with polyangiitis—autoimmune diseases associated with scleritis—and has demonstrated efficacy in treatment of refractory scleritis in patients with those diseases, as well as cases associated with other autoimmune disorders and idiopathic cases.
