Pharmacotherapy of scleritis: current paradigms and future directions

Abstract

Introduction Scleritis is an inflammatory condition affecting the eye wall that may be associated with a number of systemic inflammatory diseases. Because scleritis can be refractory to standard treatment, knowledge of the body of available and emerging therapies is paramount and is reviewed here. Areas Covered This review focuses on both traditional and emerging therapies for non-infectious scleritis. We will cover the mechanisms of action and potential adverse effects of each of the treatment modalities. Additionally, a summary of the significant MEDLINE indexed literature under the subject heading “scleritis,” “treatment,” “immunomodulator” will be provided on each therapy, including commentary on appropriate use and relative contraindications. Lastly, novel treatments and potential drug candidates that are currently being evaluated in clinical trials with therapeutic potential will also be reviewed. Expert Opinion While oral non-steroidal anti-inflammatory drugs (NSAIDs) and oral corticosteroids are widely used, effective, first-line agents for inflammatory scleritis, refractory cases require anti-metabolites, T cell inhibitors, or biologic response modifiers. In particular, there is emerging evidence for the use of targeted biologic response modifiers, and potentially, for local drug delivery.

Management of necrotizing scleritis after pterygium surgery with rituximab

“…Medical management of SINS after pterygium surgery includes immunosuppression with the oral steroids methylprednisolone + cyclophosphamide or tacrolimus for patients who do not respond to cyclophosphamide and azathioprine (4) . Surgical intervention in the form of patch grafts of scleral, corneal, or amniotic membranes (10) has also been reported.…”

“…Therefore, it is important to be alert to the risks of scleritis after such surgical procedures, particularly those that can lead to the damage of avascular tissue, such as sclera, because the risks of necrosis and infections are considerably increased. Early diagnosis and prompt immunosup pression is required for the successful management of this complication (4) . The CD20 antibody rituximab is now an option that can be used for the treatment of these special cases.…”

“…Surgically induced necrotizing scleritis (SINS) occurs after ocular surgeries for cataract extraction, trabeculectomy, strabismus, and pterygium retinal detachment (3) . The diagnosis and treatment of these special cases using immunosuppressive patch grafts or amniotic membrane grafts should be prompt (4) . Immunosuppressive agents used to treat these conditions include azathioprine, cyclophosphamide, tacrolimus, and high-dose pulse methylprednisolone (4) .…”

“…The diagnosis and treatment of these special cases using immunosuppressive patch grafts or amniotic membrane grafts should be prompt (4) . Immunosuppressive agents used to treat these conditions include azathioprine, cyclophosphamide, tacrolimus, and high-dose pulse methylprednisolone (4) . Although other biological agents can be used, particularly for the treatment of necrotizing scleritis, which potentially represents vasculitis, rituximab is generally recommended for the treatment of systemic vasculitis (5) .…”

Management with Nonsteroidal Anti-inflammatory Agents

“…Systemic NSAIDs are to be utilized as first-line agents in many patients with scleritis; some experts recommend maintaining a low threshold of initiation, given the high patient response rates and low risk of systemic side effects [9,10]. In anterior scleritis, reports of overall patient response rates range from 30 to 92% [4,11].…”