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Dutta Majumder P, Agarwal S, Shah M, Srinivasan B, K P, Iyer G, Sharma N, Biswas J, McCluskey P. Necrotizing Scleritis: A Review. Ocul Immunol Inflamm 2023:1-15. [PMID: 37279404 DOI: 10.1080/09273948.2023.2206898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 06/08/2023]
Abstract
Necrotizing scleritis is the most destructive and vision-threatening form of scleritis. Necrotizing scleritis can occur in systemic autoimmune disorders and systemic vasculitis, as well as following microbial infection. Rheumatoid arthritis and granulomatosis with polyangiitis remain the commonest identifiable systemic diseases associated with necrotising scleritis. Pseudomonas species is the most common organism causing infectious necrotizing scleritis, with surgery the most common risk factor. Necrotizing scleritis has the highest rates of complications and is more prone to secondary glaucoma and cataract than other phenotypes of scleritis. The differentiation between non-infectious and infectious necrotizing scleritis is not always easy but is critical in the management of necrotizing scleritis. Non-infectious necrotizing scleritis requires aggressive treatment with combination immunosuppressive therapy. Infectious scleritis is often recalcitrant and difficult to control, requiring long-term antimicrobial therapy and surgical debridement with drainage and patch grafting due to deep-seated infection and the avascularity of the sclera.
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Affiliation(s)
| | - Shweta Agarwal
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Mauli Shah
- Department of Uvea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Bhaskar Srinivasan
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Priyadarshini K
- Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Geetha Iyer
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Namrata Sharma
- Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jyotirmay Biswas
- Department of Uvea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Peter McCluskey
- Save Sight Institute, The University of Sydney, Sydney, Australia
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Kabaalioğlu Güner M, Mehra A, Smith WM. Novel strategies for the diagnosis and treatment of scleritis. EXPERT REVIEW OF OPHTHALMOLOGY 2021. [DOI: 10.1080/17469899.2021.1984881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Ankur Mehra
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
| | - Wendy M. Smith
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
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Risk of Chronic Obstructive Pulmonary Disease Exacerbation in Patients Who Use Methotrexate-A Nationwide Study of 58,580 Outpatients. Biomedicines 2021; 9:biomedicines9060604. [PMID: 34073252 PMCID: PMC8229017 DOI: 10.3390/biomedicines9060604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/13/2021] [Accepted: 05/21/2021] [Indexed: 11/16/2022] Open
Abstract
Patients with severe chronic obstructive pulmonary disease (COPD) experience frequent acute exacerbations and require repeated courses of corticosteroid therapy, which may lead to adverse effects. Methotrexate (MTX) has anti-inflammatory properties. The objective of this study was to describe the risk of COPD exacerbation in patients exposed to MTX. In this nationwide cohort study of 58,580 COPD outpatients, we compared the risk of hospitalization-requiring COPD exacerbation or death within 180 days in MTX vs. non-MTX users in a propensity-score matched study population as well as an unmatched cohort, in which we adjusted for confounders. The use of MTX was associated with a reduction in risk of COPD exacerbation in the propensity-score matched population at 180 days follow-up (HR 0.66, CI 0.66–0.66, p < 0.001). Similar results were shown in our sensitivity analyses at 180-day follow-up on unmatched population and 365-day follow-up on matched and unmatched population (HR 0.76 CI 0.59–0.99, HR 0.81 CI 0.81–0.82 and HR 0.92 CI 0.76–1.11, respectively). MTX was associated with a lower risk of COPD exacerbation within the first six months after study entry. The finding seems biologically plausible and could potentially be a part of the management of COPD patients with many exacerbations.
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Sands DS, Chan SCY, Gottlieb CC. Methotrexate for the treatment of noninfectious scleritis. Can J Ophthalmol 2018; 53:349-353. [PMID: 30119788 DOI: 10.1016/j.jcjo.2017.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/09/2017] [Accepted: 11/20/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess corticosteroid-sparing and inflammation control in patients with noninfectious scleritis treated with methotrexate. DESIGN Retrospective review. PARTICIPANTS Patients who received methotrexate treatment for noninfectious scleritis and who had 12 months of follow-up after treatment initiation were included in this review. METHODS The clinical records of noninfectious scleritis patients presenting at the University of Ottawa Eye Institute between September 1, 2010 and December 31, 2014 treated with methotrexate were retrospectively reviewed. Seventeen patients (21 eyes) were included in the study. Main outcome included inflammation control and corticosteroid-sparing success. Secondary outcomes were reduction of immunosuppression load and best-corrected visual acuity. RESULTS The proportion of eyes with corticosteroid-sparing success was 69.2% at 3 months and 92.3% at 12 months. The proportion of eyes that achieved inflammation control was 61.9% at 3 months and 90.5% at 12 months. The corticosteroid immunosuppression load at treatment start was 1.9 ± 2.07 and at 12 months was 0.48 ± 1.03 (p < 0.01). There was no statistically significant difference in best-corrected visual acuity. CONCLUSIONS The treatment of noninfectious scleritis with methotrexate appears to be effective at both achieving steroid-sparing success and controlling inflammation during 12 months of therapy. Immunosuppression load decreased significantly over 12 months of therapy while best corrected visual acuity was stable.
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Affiliation(s)
- David S Sands
- Faculty of Medicine, University of Ottawa, Ottawa, Ont..
| | - Stephanie C Y Chan
- Faculty of Medicine, University of Ottawa, Ottawa, Ont.; University of Ottawa Eye Institute, Ottawa, Ont
| | - Chloe C Gottlieb
- Faculty of Medicine, University of Ottawa, Ottawa, Ont.; University of Ottawa Eye Institute, Ottawa, Ont.; Ottawa Hospital Research Institute, Ottawa, Ont
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Mucoadhesive nanostructured polyelectrolytes complexes modulate the intestinal permeability of methotrexate. Eur J Pharm Sci 2018; 111:73-82. [DOI: 10.1016/j.ejps.2017.09.042] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/11/2017] [Accepted: 09/26/2017] [Indexed: 12/25/2022]
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Daniel Diaz J, Sobol EK, Gritz DC. Treatment and management of scleral disorders. Surv Ophthalmol 2016; 61:702-717. [DOI: 10.1016/j.survophthal.2016.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 12/12/2022]
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Ozzello DJ, Kolfenbach JR, Palestine AG. Uveitis Specialists and Rheumatologists Select Different Therapies for Idiopathic Non-necrotizing Anterior Scleritis. Ophthalmol Ther 2016; 5:245-252. [PMID: 27744531 PMCID: PMC5125128 DOI: 10.1007/s40123-016-0067-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Indexed: 12/17/2022] Open
Abstract
Introduction Uveitis specialists and rheumatologists treat patients with anterior scleritis, but data from controlled trials to guide management are scarce, making differences in treatment paradigms possible. Methods 1044 uveitis specialists and rheumatologists were surveyed regarding therapy for a patient with anterior scleritis. Respondents were asked to select first- and second-choice therapies and then reselect therapies assuming that the costs of all options were equal and that insurance approval was ensured. Fisher’s exact tests were employed to compare selections. Results Ninety-two respondents (8.6%) completed the survey. Methotrexate was the most-selected first-choice treatment before equalization of cost/insurance factors among uveitis specialists (44.4%) and rheumatologists (78.6%) (p < 0.009). Uveitis specialists selected mycophenolate at a higher rate (27.8%) than did rheumatologists (5.3%) (p < 0.015). Cost and insurance considerations were not significant. Conclusions Uveitis specialists and rheumatologists have different preferences in the treatment of anterior scleritis. The difference is impacted more by specialty practice than by cost/insurance.
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Affiliation(s)
- Daniel J Ozzello
- Department of Ophthalmology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Jason R Kolfenbach
- Division of Rheumatology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Alan G Palestine
- Department of Ophthalmology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.
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Oray M, Meese H, Foster CS. Diagnosis and management of non-infectious immune-mediated scleritis: current status and future prospects. Expert Rev Clin Immunol 2016; 12:827-37. [DOI: 10.1586/1744666x.2016.1171713] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Merih Oray
- Istanbul Faculty of Medicine, Department of Ophthalmology, Istanbul University, Istanbul, Turkey
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham, MA, USA
- Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Halea Meese
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham, MA, USA
- Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - C. Stephen Foster
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham, MA, USA
- Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Subconjunctival sirolimus in the treatment of autoimmune non-necrotizing anterior scleritis: results of a phase I/II clinical trial. Am J Ophthalmol 2015; 159:601-6. [PMID: 25526946 DOI: 10.1016/j.ajo.2014.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 12/20/2022]
Abstract
PURPOSE To investigate the safety, tolerability and efficacy of subconjunctival sirolimus injections as a treatment for active, autoimmune, non-necrotizing anterior scleritis. DESIGN Phase I/II, single-center, open-label, nonrandomized, prospective pilot study. METHODS Five participants with active, autoimmune, non-necrotizing anterior scleritis with scleral inflammatory grade of ≥1+ in at least 1 quadrant with a history of flares were enrolled. A baseline injection was given, with the primary outcome measure of at least a 2-step reduction or reduction to grade zero in the study eye by 8 weeks. Secondary outcomes included changes in visual acuity and intraocular pressure, ability to taper concomitant immunosuppressive regimen, and number of participants who experienced a disease flare requiring reinjection. Safety outcomes included the number and severity of systemic and ocular toxicities, and vision loss ≥15 ETDRS letters. The study included 6 visits over 4 months with an extension phase to 1 year for participants who met the primary outcome. RESULTS All participants (N = 5, 100%; 95% CI [0.60, 1.00]) met the primary outcome in the study eye by the week 8 visit. There was no significant change in mean visual acuity or intraocular pressure. Three out of 5 patients (60%) experienced flares requiring reinjection. No systemic toxicities were observed. Two participants (40%) experienced a localized sterile inflammatory reaction at the site of the injection, which resolved without complication. CONCLUSIONS Subconjunctival sirolimus leads to a short-term reduction in scleral inflammation, though relapses requiring reinjection do occur. There were no serious adverse events, though a local sterile conjunctival inflammatory reaction was observed.
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Ragam A, Kolomeyer AM, Fang C, Xu Y, Chu DS. Treatment of Chronic, Noninfectious, Nonnecrotizing Scleritis with Tumor Necrosis Factor Alpha Inhibitors. Ocul Immunol Inflamm 2013; 22:469-77. [DOI: 10.3109/09273948.2013.863944] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Use of hydroxychloroquine in corticodependent and recurrent scleritis. Graefes Arch Clin Exp Ophthalmol 2013; 251:989-90. [DOI: 10.1007/s00417-011-1922-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 12/19/2011] [Accepted: 12/29/2011] [Indexed: 10/14/2022] Open
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Beardsley RM, Suhler EB, Rosenbaum JT, Lin P. Pharmacotherapy of scleritis: current paradigms and future directions. Expert Opin Pharmacother 2013; 14:411-24. [PMID: 23425055 DOI: 10.1517/14656566.2013.772982] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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 noninfectious scleritis. The authors cover the mechanisms of action and potential adverse effects of each of the treatment modalities. In addition, 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. 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 nonsteroidal anti-inflammatory drugs and oral corticosteroids are widely used, effective, first-line agents for inflammatory scleritis, refractory cases require antimetabolites, 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.
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Affiliation(s)
- Robert M Beardsley
- Oregon Health & Science University, Casey Eye Institute, 3375 SW Terwilliger Blvd, Portland, OR 97239, USA
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Wieringa WG, Wieringa JE, ten Dam-van Loon NH, Los LI. Visual Outcome, Treatment Results, and Prognostic Factors in Patients with Scleritis. Ophthalmology 2013. [DOI: 10.1016/j.ophtha.2012.08.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Kolomeyer AM, Ragam A, Shah K, Do BK, Shah VP, Chu DS. Cyclo-oxygenase Inhibitors in the Treatment of Chronic Non-infectious, Non-necrotizing Scleritis and Episcleritis. Ocul Immunol Inflamm 2012; 20:293-9. [DOI: 10.3109/09273948.2012.689075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kolomeyer AM, Ragam A, Shah K, Jachens AW, Tu Y, Chu DS. Mycophenolate Mofetil in the Treatment of Chronic Non-infectious, Non-necrotizing Scleritis. Ocul Immunol Inflamm 2012; 20:113-8. [DOI: 10.3109/09273948.2012.655398] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Biber JM, Schwam BL, Raizman MB. Scleritis. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00111-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Gabison E, Hoang-Xuan T. Sclérites : quand évoquer une pathologie systémique ? J Fr Ophtalmol 2010; 33:593-8. [DOI: 10.1016/j.jfo.2010.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 06/30/2010] [Indexed: 10/19/2022]
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Johnson KS, Chu DS. Reply. Am J Ophthalmol 2010. [DOI: 10.1016/j.ajo.2010.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Johnson KS, Chu DS. Evaluation of sub-Tenon triamcinolone acetonide injections in the treatment of scleritis. Am J Ophthalmol 2010; 149:77-81. [PMID: 19875093 DOI: 10.1016/j.ajo.2009.07.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Revised: 07/27/2009] [Accepted: 07/28/2009] [Indexed: 02/07/2023]
Abstract
PURPOSE To suggest that sub-Tenon triamcinolone acetonide (TA) injections may be a helpful supplement in patients with scleritis. DESIGN Retrospective, interventional case series. METHODS A retrospective chart review was conducted of all patients at our institution receiving sub-Tenon TA injections for scleritis between August 2001 and August 2007. Outcome measures included subjective improvement, presence of inflammation, and adverse events. RESULTS Eleven patients (12 eyes) were included in this study. The mean age was 50 years; 2 patients were male and 9 female. Six patients had systemic autoimmune disease. All patients were receiving systemic medications for scleritis at the time of injection. Mean initial follow-up time was 3 weeks. Ten of 11 patients reported subjective improvement, and 10 patients had improvement in objective inflammation. Three patients had adverse side effects, including ocular hypertension, worsening of cataract, and subconjunctival hemorrhage with periorbital ecchymosis. CONCLUSIONS Sub-Tenon TA injections may be a useful adjunct to achieving transient, partial improvement of subjective pain and objective inflammation in patients with scleritis while awaiting systemic medications to take effect. Adverse events were manageable in this small series.
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