Use of cyclosporin in the management of steroid dependent non-necrotising scleritis.

Abstract

Many patients with non-necrotising scleritis can be treated adequately with non-steroidal anti-inflammatory drugs or steroids. But, as many ofthem are young, treatment may present problems if they require high doses of steroids to control the scleral inflammation and then relapse when the dosage is reduced. Five such patients were treated with a combination of steroids and low-dose cyclosporin therapy, and in all cases the scleritis remained under control on a much lower dose of steroids than when steroids were used alone. Cyclosporin is therefore a useful drug in the management of younger patients dependent on high-dose steroids to control their scleral inflammation.Anterior scleritis can be diffuse, nodular, or necrotising.' In many patients non-steroidal anti-inflammatory drugs (NSAIDS), such as flurbiprofen, can be used to control diffuse or nodular scleritis, whereas high-dose steroids, often with other potent immunosuppressives such as cyclophosphamide, are necessary for the treatment of necrotising scleritis.2 Cyclosporin, which is used extensively in the treatment of posterior uveitis, has previously been described in the treatment of necrotising disease, which usually occurs in older patients.3We here present five patients with severe anterior diffuse scleritis in whom systemic prednisolone was effective only at high dosage or could not be tolerated at such doses. Any attempt at steroid reduction resulted in severe recurrence of the scleral inflammation. These patients received low-dose cyclosporin (5 mg/kg/day) in addition to the controlling steroid dose, and in all cases the steroid dosage could then be reduced to a more acceptable level while the scleral inflammation remained under control. stopped completely. If the disease relapsed as the steroids were reduced, then NSAID were sometimes combined with the steroids to attempt disease control. If the inflammation could not be controlled on a satisfactorily low steroid level, the steroids were increased back to or above the controlling dose, and cyclosporin A added, at 5 mg/kg/day, in two divided doses, after the serum creatinine was checked and found to be within the normal range. After one or two weeks on the combination therapy slow steroid reduction was attempted.The cyclosporin dose was monitored by twoweekly serum creatinine measurements and adjusted if the creatinine started to rise. If relapse occurred while treatment was being reduced, the prednisolone dose was increased and then again slowly tapered off. The cyclosporin was also increased, if thought necessary, but to a maximum dose of 7-5 mg/kg/day for up to a week, before being reduced back to 5 mg/kg/day. ResultsFive patients with non-necrotising scleritis received cyclosporin. Their ages ranged from 21 to 64 years, average 32. Systemic investigations revealed Crohn's disease with primary sclerosing cholangitis in one patient and nasal cartilage collapse in another (possibly indicative of relapsing polychondritis). The others were healthy. In four patients satisfactory control of t...

Cells perpetuating the inflammatory response in scleritis.

“…Further evidence for the involvement of T cell mediated mechanisms is provided by reports of successful treatment of active scleritis with cyclosporin A. [12][13][14] Although there is evidence of a T cell mediated (autoimmune) disorder at some stage of scleritis, our study does not allow conclusions on the initiating mechanisms of non-infectious scleritis. This is due to the fact that when biopsy specimens are investigated, the disease has already existed for some time, and it is likely that primary events are masked by secondary phenomena.…”

Therapy Insight: scleritis and its relationship to systemic autoimmune disease

“…Options include methotrexate, azathioprine, mycophenolate mofetil and ciclosporin. [35][36][37][38][39][40][41] The choice of agent will depend in part on the presence of an underlying disease as well as other issues, which include the patient's alcohol intake, liver function, and blood pressure. The treatment for scleritis might be dictated by the therapy for any underlying systemic illness.…”

The eye in systemic vasculitis

“…Non-necrotising scleritis disease may respond to non-steroidal anti-inflammatory drugs, but necrotising disease must be treated with high dose corticosteroids very quickly as the integrity of the eye is compromised. Additional immunosuppressive therapy may be required with drugs such as cyclosporin, 22 azathioprine, mycophenolate, 23 methotrexate, 24 or less commonly cyclophosphamide if the corticosteroids are ineffective or too high a dose is required for disease control. Corneal perforation may require the application of glue or a tectonic graft to seal the hole in addition to the systemic medication.…”