The diagnosis and management of anterior scleritis

Role of anterior segment optical coherence tomography in scleral diseases: A review

BACKGROUND

Scleritis and episcleritis are an overlapping spectrum of diseases and accurate diagnosis is of utmost importance as the treatment and prognosis are vastly different. Predominantly a clinical diagnosis, the challenge lies in those cases with equivocal clinical features. Furthermore, clinical grading of scleritis is subjective and hence is neither very reliable nor reproducible. Existing modalities such as slit lamp examination and clinical photographs in scleritis describe macroanatomy but do not provide details on the microanatomy of the sclera. A recent adjusted algorithm for anterior segment optical coherence tomography (AS-OCT) imaging has improved the ability of this device to aid in the diagnosis of all the major forms of scleritis.

PURPOSE

To highlight the role of AS-OCT in delineating various anatomical forms of episcleritis and scleritis and explore this tool in monitoring disease course and response to therapy.

METHODS

A comprehensive literature search was carried out in various medical databases using keywords AS-OCT and scleritis; AS-OCT and episcleritis; anterior segment imaging in scleritis; scleritis and episcleritis; Recent advances in anterior segment imaging. Original articles and novel reports describing the potential role of AS-OCT in the diagnosis and management of scleritis and episcleritis were included.

RESULTS

After a thorough assessment, it was clear that published literature lacks guidelines for uniform interpretation and also for classification and follow-up in scleritis. We describe a uniform protocol for AS-OCT image acquisition, interpretation of images and list the advantages and limitations.

CONCLUSIONS

AS-OCT can be used to localize the level of scleral inflammation thus helping in the diagnosis of scleral inflammatory disease. It can be a valuable tool in studying progression.

A novel technique of full-thickness scleral debridement in fulminant necrotising infectious scleritis and its outcomes-a consecutive case series

PURPOSE

To report the outcomes of a novel technique of scleral debridement in five consecutive cases of relentlessly progressive and fulminant infectious scleritis following corticosteroid exposure.

METHODS

Five consecutive patients of infectious scleritis with a common history of corticosteroids exposure, resulting from either an initial misdiagnosis of autoimmune scleritis or as anti-inflammatory adjunct to specific antimicrobial therapy. Data collection included presentation details such as photographs, clinical findings, microbiological analysis, treatment details and audit of surgical videos. Cases with undisputed diagnosis of infectious scleritis with microbiological evidence, without corticosteroid use, were excluded from  the study.

RESULTS

After full-thickness scleral debridement and cessation of corticosteroids, favourable anatomical and visual outcome was observed in all cases; however, two patients required multiple scleral debridements due to progressive scleritis. Scleral patch graft was not used in any case. Microbiology detected infective organisms in two cases, while the remaining revealed negative results. Therefore, specific antimicrobial therapy was initiated in former, whereas empirical broad-spectrum regimen in patients with repeatedly negative microbiological results. No recurrence of scleritis or development of ciliary staphyloma was noted and anatomical integrity was maintained with normal intraocular pressure during follow-up.

CONCLUSION

This study highlights the fulminant and relentlessly progressive clinical course, that infectious scleritis can metamorphose into, despite specific antimicrobial therapy, if inadvertent corticosteroid therapy is administered. Full-thickness debridement without scleral patch graft, could achieve elimination of infectious foci, with favourable long-term anatomical and visual outcome. This technique could offer a potential last-resort approach in such cases where standard therapeutic modalities have not been successful.

Inpatient Ophthalmology Consultations

Comprehensive patient care requires an integrated approach that often includes different specialties. Of these specialties, Ophthalmology stands out with its variable pathologic conditions, unique tools, and special examination techniques, which are not part of the standard training of internal medicine or other specialties. The authors review prior studies focused on inpatient ophthalmology consultations, common reasons for inpatient ophthalmology consultation, and the recommended approach to the most common ocular complaints that could present to the inpatient provider. They also shed light on the basic ocular history and eye examination that should be obtained before requesting an ophthalmic evaluation.

Necrotising fungal scleritis with full-thickness scleral melt and circumferential progression: a novel debridement approach

A 44-year-old Asian Indian woman presented with a history of pain and redness in the left eye for 3 weeks. Scleral congestion with a nodular swelling was present inferotemporally. Raised C reactive protein and positive antinuclear and perinuclear antineutrophil cytoplasmic antibodies suggested autoimmune scleritis. The patient was therefore managed with corticosteroids. Nevertheless, the development of severe pain associated with a scleral abscess led to a revised diagnosis of infectious scleritis. Corticosteroids therapy was halted and urgent debridement was performed. Microbiology confirmed fungal scleritis due to Coprinopsis cinerea Multiple full-thickness circumferential debridements with antifungal therapy resulted in satisfactory anatomical and visual outcomes. This case presented a unique challenge, since laboratory results were misleading, and corticosteroids resulted in a fulminant clinical course. Therefore, aggressive circumferential debridement was performed to achieve the elimination of a rare fungal aetiology of scleritis, which has not been reported previously to cause human infection.

Current Approach for the Diagnosis and Management of Noninfective Scleritis

ABSTRACT

Scleritis is a rare, vision-threatening inflammation of the sclera that is often associated with life-threatening systemic illnesses. Rheumatoid arthritis remains the most common associated systemic rheumatic disease and the commonest systemic association of scleritis. Granulomatosis with polyangiitis is the most common cause of vasculitis-associated scleritis. The etiopathogenesis of scleritis remains unclear, but can be immune complex-mediated or due to a local delayed hypersensitivity reaction. Scleritis can involve either the anterior or posterior sclera, and has a wide spectrum of clinical presentations. Among the subtypes of scleritis, necrotizing scleritis has an increased risk of complications and is more commonly associated with anterior uveitis and peripheral ulcerative keratitis. Posterior scleritis is often not diagnosed or missed due to its subtle clinical signs and protean manifestations. Meticulous history taking, detailed ocular examination, and a targeted array of investigations with a multi-disciplinary approach to find any underlying systemic disease are crucial for the management of a case of scleritis. Corticosteroids remain the mainstay of short-term treatment of scleritis; mild to moderate scleral inflammation may respond well to treatment with nonsteroidal antiinflammatory drug or topical corticosteroid. Corticosteroid-sparing immunosuppressive therapies are useful in cases with an inadequate response or failure to provide long-term control of inflammation, and to prevent recurrence of scleritis. Biologic agents are increasingly used in the management of scleritis, not responding to the conventional therapies. This review provides an overview of the various subtypes of scleritis and its systemic associations and evaluates current trends in the diagnosis and management of noninfective scleritis.

Effectiveness of pharmacological agents for the treatment of non-infectious scleritis: a systematic review protocol

BACKGROUND

Non-infectious scleritis is a potentially sight-threatening condition in which the sclera, the white outer layer of the eye, becomes inflamed. Whilst scleritis can be infective, the majority of cases are due to non-infectious causes, often occurring in association with an underlying systemic autoimmune or auto-inflammatory condition. Thorough systemic work-up is crucial to identify disease aetiology and exclude infection; however, a significant proportion of disease remains idiopathic with the underlying cause unknown. Non-infectious scleritis is normally managed with systemic corticosteroid and immunosuppression, yet there is no widely agreed consensus on the most appropriate therapy, and no national or international guidelines exist for treatment of non-infectious scleritis.

METHODS

Standard systematic review methodology will be used to identify, select and extract data from comparative studies of pharmacological interventions used to treat patients with non-infectious scleritis. Searches of bibliographic databases (Cochrane Library, MEDLINE, CINAHL and EMBASE) and clinical trial registers will be employed. No restrictions will be placed on language or date of publication. Non-English articles will be translated where necessary. The primary outcome of interest will be disease activity measured by reduction in scleritis grading according to standardised grading systems. Secondary outcomes will include change in best corrected visual acuity, reduction in concurrent dose of systemic corticosteroid, time to treatment failure, adverse events and health-related quality of life. Risk of bias assessment will be conducted appropriate to each study design. Study selection, data extraction and risk of bias assessment will be completed by two reviewers independently. Data will be presented in a table and a narrative synthesis will be undertaken. Meta-analysis will be performed where methodological and clinical homogeneity exists. Subgroup and sensitivity analysis will be undertaken if appropriate.

DISCUSSION

Many studies have investigated the effectiveness of pharmacological agents used in the management of non-infectious scleritis. A systematic review is needed to collate and analyse this evidence. Findings of this systematic review will help guide ophthalmologists managing patients with non-infectious scleritis and may form the basis for evidence-based recommendations for future clinical practice and encourage standardisation of treatment protocols.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019125198.

[Diagnosis and treatment of episcleritis and scleritis]

Episcleritis is a benign and self-limiting disease, often with a recurrent course, manifesting mainly in young adults. In less than a third of patients, an associated systemic disease can be found. In contrast, scleritis is observed mainly in patients between the 4th and 6th decade of life, may lead to severe ocular complications, and is often associated with a systemic rheumatological disease. Diffuse, nodular, and necrotizing forms of scleritis can be differentiated. Necrotizing and posterior scleritis have a higher risk of complications and worse visual outcome. In most cases, medical history and slit lamp examination allow differentiation of episcleritis and scleritis. Whereas episcleritis is treated mainly symptomatically with artificial tears, topical corticosteroids, and potentially with systemic nonsteroidal anti-inflammatory drugs, scleritis requires early and aggressive anti-inflammatory treatment in a stepwise approach.

Ocular Pharmacology for Scleritis: Review of Treatment and a Practical Perspective

Scleritis is defined as an infectious or noninfectious inflammation of the sclera that can be broadly categorized according to anatomic location (ie, anterior or posterior) and whether the process is necrotizing or non-necrotizing. Treatment for scleritis is dictated by the etiology of the inflammation, with infectious forms requiring treatment of the inciting agent and noninfectious forms requiring treatment of the underlying inflammation with immunosuppression. Pharmacotherapy for noninfectious scleritis can be classified according to delivery route (eg, local or systemic) and mechanism of action (eg, biologic or nonbiologic). This review will briefly summarize the classification scheme for scleritis before reviewing in depth both systemic and local pharmacotherapies that can be used to effectively treat an eye afflicted by either infectious or noninfectious scleritis. Traditional anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs, steroids, and immunomodulatory therapy will be discussed, as well as newer biologic therapies such as antitumor necrosis factor alpha and anti-CD20 agents.

Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS)-report 4: analysis and outcome of scleritis in an East Asian population

Background

The purpose of this study is to evaluate the spectrum of scleritis from database of Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) at a tertiary eye referral eye institute in Singapore. Clinical records of 120 patients with scleritis from a database of 2200 patients from Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) were reviewed.

Results

56.6% were females, with a mean age of 48.6 ± 15.9 years. 75 (62.5%) had diffuse anterior scleritis, 25 (20.8%) had nodular anterior scleritis, 7 (5.8%) had necrotizing anterior scleritis and 13 (10.8%) had posterior scleritis. Ocular complications were observed in 53.3% of patients, including anterior uveitis (42.5%), raised intraocular pressure (12.5%), and corneal involvement (11.7%). Autoimmune causes were associated with 31 (25.8%) of patients, and 10 (8.3%) patients had an associated infective etiology, much higher than Caucasian studies. 53.3% of patients were treated with oral corticosteroids while 26.7% required immunosuppressives.

Conclusions

Infective etiology needs to be considered in patients of scleritis from Asian origin. In our study and in OASIS database, scleritis was associated with systemic autoimmune disease and ocular complications.

High-resolution ultrasound biomicroscopy as an adjunctive diagnostic tool for anterior scleral inflammatory disease

PURPOSE

To study high-resolution ultrasound biomicroscopy (UBM) findings in anterior scleral inflammatory disease and evaluate the efficacy of high-resolution UBM as an adjunctive diagnostic tool.

METHODS

A cross-sectional study. The medical records of 30 patients (33 eyes) with episcleritis or anterior scleritis were reviewed for clinical features and high-resolution UBM findings. Ultrasound biomicroscopy (UBM) examination was performed using 50 MHz Aviso S (Quantel Medical, Clermont-Ferrand, France).

RESULTS

Seventeen eyes had episcleritis [nodular (12), simple (five)], and 16 eyes had anterior scleritis [nodular (14), diffuse (two)] as classified by UBM. The use of high-resolution UBM allowed high-resolution imaging of the sclera and episclera and showed characteristic patterns of episcleritis and anterior scleritis. The clinical classification matched UBM findings in 25 (76%) eyes. In the other eight eyes (24%), UBM analysis led to a change in the final classification: four eyes with suspected episcleritis were classified with scleritis, and four eyes with suspected scleritis were classified with episcleritis. Eleven patients (36.7%) had an associated systemic disease.

CONCLUSION

High-resolution UBM enabled visualization of distinct imaging findings of episcleritis and anterior scleritis, indicating its usefulness in the classification of challenging cases of anterior scleral inflammatory disease.

Flurbiprofen: A Nonselective Cyclooxygenase (COX) Inhibitor for Treatment of Noninfectious, Non-necrotizing Anterior Scleritis

OBJECTIVE

To analyze the safety and efficacy of a nonselective cyclo-oxygenase (COX) inhibitor in the management of noninfectious, non-necrotizing anterior scleritis.

METHODS

Retrospective chart review of 126 patients with non-necrotizing anterior scleritis treated with oral flurbiprofen (Froben®(Abbott Healthcare)) with (Group B, n = 61) or without (Group A, n = 65) topical steroids was performed and time to remission was plotted.

RESULTS

The observed incidence rate was 1.07 (95% CI: 0.57-1.99) per 1000 person-years with failure rate of 0.68 (95% CI: 0.22-2.12) per 1000 person-years in Group A and 1.41 (95% CI: 0.67-2.96) per 1000 person-years in Group B. The failure rate was 3.97 (1.89-9.34) per 1000 person-years with hazard ratio of 10.01 (95% CI: 2.52-39.65; p < 0.001) for patients with associated systemic disease.

CONCLUSION

To the of our best knowledge, this is the first and largest case series on the safety and efficacy of a nonselective COX inhibitor in the management of anterior scleritis.

Ocular toxoplasmosis associated with scleritis

We report an atypical presentation of Toxoplasma retinochoroiditis with associated scleritis in a young and immunocompetent patient. The diagnosis was done on the basis of Polymerase chain reaction of vitreous sample, and the clinical response to specific treatment. This case highlights the unusual presentation of ocular toxoplasmosis as scleritis.

Clinical features of patients with episcleritis and scleritis in an Italian tertiary care referral center

PURPOSE

To evaluate demographic characteristics, clinical features, systemic disease associations, visual outcomes, and treatment modalities of patients with episcleritis and scleritis in an Italian tertiary care referral center.

METHODS

Data from 25 patients with episcleritis and from 85 patients with scleritis followed from 2003 to 2012 were retrospectively evaluated. The main outcome measures were demographics, ocular disease characteristics, presence of systemic associated disease, treatment regimen, and follow-up period.

RESULTS

Episcleritis and scleritis were found bilaterally in 24% and 31% of patients, respectively (p<0.521). The episcleritis was diffuse in 15 and focal in 10 patients, while the scleritis was diffuse in 49, nodular in 28, necrotizing in 6, and posterior in 2 patients. Anterior uveitis (4% vs 31%; p<0.006), peripheral ulcerative keratitis (0% vs 14%; p<0.167), ocular hypertension (0% vs 7%; p<0.333), and a decrease in visual acuity (4% vs 19%; p<0.112) were encountered as ocular complications in patients with episcleritis and patients with scleritis, respectively. An associated systemic disease was found in 20% and 52% of patients with episcleritis and patients with scleritis (p<0.004). Among patients with episcleritis, 76% required topical corticosteroid treatment to achieve disease resolution, 16% oral nonsteroidal anti-inflammatory drugs (NSAIDs), and 8% antivirals; 39% of patients with scleritis required systemic NSAIDs, 12% oral corticosteroids, 34% immunosuppressive drugs, and 15% antibiotics or antivirals.

CONCLUSIONS

The importance of differentiating scleritis from episcleritis is remarkable given the significant difference in the degree of ocular complications and associated systemic diseases between these ocular conditions. Prompt diagnosis, systemic assessment, and treatment are fundamental in all patients with scleral inflammation.

Contact lens-associated nocardial necrotizing scleritis

A 52 year-old, contact lens-wearing man presented with progressive right eye pain and redness for one month. He had been evaluated and treated for necrotizing scleritis by multiple eye care specialists prior to presentation. He underwent a complete systemic work-up for both autoimmune and infectious causes of scleritis, including a culture. The culture revealed heavy growth of Nocardia asteroides complexes. The patient was treated with topical amikacin and oral Bactrim. Following several weeks of antibiotic treatment, the patient's infection resolved completely, and his visual acuity returned to baseline status. Nocardia is a rare but potentially devastating cause of necrotizing scleritis that may affect contact lens wearers without an associated keratitis. Prompt recognition and early treatment with appropriate antimicrobial agents are critical to achieve a favorable outcome.

Scleritis: Immunopathogenesis and molecular basis for therapy

Scleritis is a heterogeneous group of diseases characterized by inflammation of the sclera, which may be due to local or systemic infections or immune mediated diseases. Numerous studies over the last decade have lead to significant progress in understanding the pathogenesis and treatment of this severe and potentially blinding disease. Immunological investigations of non-infectious scleritis and associated diseases have indicated that scleritis is an autoimmune disease and studies on the nature of the local inflammatory response have revealed the prominent role of T and B cells and cytokines, such as TNF-alpha, which in turn has resulted in clinical trials showing the effectiveness of local steroid treatment, anti-TNF and anti-B cell therapy. The widespread use of imaging has led to the realization that posterior scleritis is more common than previously recognized and testing for ANCA antibodies has revealed the prominent role of immune mechanisms in a subset of patients with scleritis and associated systemic vasculitis.

Clinico-microbiological profile and treatment outcome of infectious scleritis: experience from a tertiary eye care center of India

Medical and microbiology records of seventeen patients (17 eyes), diagnosed as scleritis of infectious origin were reviewed; to study clinical features, predisposing risk factors, microbiologic profile and treatment outcome of infectious scleritis. The mean patient age was 52.3 ± 19.75 years. Twelve patients (70.6%) had history of trauma/prior surgery. Isolated organisms included Staphylococcus species (spp) (n = 5), Fungus (n = 4), Nocardia spp (n = 3), two each of atypical Mycobacterium spp and Streptococcus pneumoniae and one Pseudomonas aeruginosa. Treatment included intensive topical antimicrobial in all eyes and systemic medication in 15 (88.2%) patients; surgical exploration was needed for 13 (76.5%) patients and scleral patch graft was done in four (23.5%) patients. Lesions resolved in all patients and none required evisceration. The presenting log MAR visual acuity of 1.77 ± 1.40 and improved to 0.99 ± 0.91. (P ≤ 0.039) after treatment with a mean follow up of 22.57 ± 19.53 weeks. A microbiological confirmation, appropriate medical and/or surgical intervention has a good tectonic and visual outcome.

An update on the cause and treatment of scleritis

PURPOSE OF REVIEW

To review new clinically relevant data regarding the cause and treatment of scleritis that has been identified over the past 36 months.

RECENT FINDINGS

A recently described T-helper cell population, known as Th-17, has been implicated in scleritis. Large-scale, retrospective reviews of standard corticosteroid-sparing systemic therapies, published in the last few years, have demonstrated only moderate efficacy for any particular immunomodulatory agent, whereas new data have confirmed excellent efficacy and tolerability to subconjunctival corticosteroids.

SUMMARY

Improved understanding of the immunopathophysiology of scleritis offers hope for future molecule-specific drug design. Data continue to support the use of local steroids as a reasonable therapeutic option for nonnecrotizing, noninfectious anterior scleritis.

Retrospective review of methotrexate therapy in the treatment of chronic, noninfectious, nonnecrotizing scleritis

PURPOSE

To determine the effectiveness and steroid-sparing capabilities of methotrexate in the treatment of chronic, noninfectious, nonnecrotizing scleritis.

DESIGN

Retrospective chart review.

METHODS

We conducted a retrospective chart review of all patients treated for scleritis between January 1, 2000 and July 31, 2005 at the Institute of Ophthalmology and Visual Science at New Jersey Medical School of the University of Medicine and Dentistry of New Jersey. Outcome measures included inflammation, corticosteroid and methotrexate dosages, visual acuity, and reported side effects.

RESULTS

Eighteen patients, with a total of 27 affected eyes, were included in the study: 15 women and three men with a mean age of 52 years. Inflammation control was achieved in 11 patients, nine women and two men. Successful corticosteroid sparing was achieved in 10 of the 11 patients, with three patients completely discontinuing corticosteroid use. Visual acuity was maintained or improved in 21 (78%) of 27 affected eyes. Eight patients reported adverse effects, with one patient discontinuing treatment because of unbearable fatigue. The dose of methotrexate ranged from 7.5 to 35 mg weekly. The mean duration of methotrexate therapy was 19 months (standard deviation, 11 months). There were no serious adverse reactions or long-term morbidity caused by methotrexate therapy.

CONCLUSIONS

Methotrexate seems to be a well-tolerated therapy that can reduce inflammation successfully and can decrease the corticosteroid requirement in the treatment of chronic, noninfectious, and nonnecrotizing scleritis.