Pharmacotherapy of scleritis: current paradigms and future directions

Effectiveness of difluprednate in addition to systemic therapy for the treatment of anterior scleritis

AIM

To describe the effectiveness and side-effect profile of adding difluprednate therapy to patients with anterior scleritis being treated systemically.

METHODS

Retrospective chart review. Charts from all patients with anterior scleritis who were treated with topical difluprednate in addition to systemic therapy from 1 January 2018 to 1 January 2020 were reviewed. Data collected included: demographics, scleritis type, systemic diagnosis, presence of nodules or necrosis, changes in scleritis activity, intraocular pressure (IOP), number of difluprednate drops used, type of systemic treatment used, best-corrected visual acuity (BCVA) and lens status. The primary outcome was clinical resolution of scleritis. Secondary outcomes included BCVA loss ≥2 lines, change in lens status or cataract surgery and IOP ≥24 mm Hg.

RESULTS

Thirty-two patients (44 eyes) were analysed. The median age was 57 years (IQR 52, 72); 59% were female; 72% were Caucasian. An associated systemic disease was present in 59%. Systemic therapies used when difluprednate was added were: 65% immunosuppressive agents, 43% prednisone and 25% non-steroidal anti-inflammatory drugs. The addition of difluprednate resulted in clinical resolution in 79.6% of the treated eyes. Median time to inactivity was 9 weeks (IQR 5, 20). Eyes initially using 2-4 drops per day had a higher response rate (89%, p=0.005). Over a median follow-up of 34 weeks (IQR 21, 74), 11 eyes had IOP elevation; 6 eyes lost ≥2 lines of BCVA, 5 eyes had cataract progression.

CONCLUSION

Most eyes treated with difluprednate achieved inactivity. The addition of difluprednate to systemic therapies provides an alternative to achieve control of inflammation.

Rhegmatogenous Retinal Detachment in Anterior Scleritis With Ulcerative Colitis

Rhegmatogenous retinal detachment (RRD) is an ocular emergency as it is sight-threatening and requires urgent surgical intervention. Ulcerative colitis (UC) is an immune-mediated inflammatory bowel disease that can present with ocular manifestations. The objective of this case report is to share the rare presentation of RRD associated with UC leading to diagnosis and management dilemmas. A 35-year-old man with active UC presented with a right chronic red eye for two months. The best corrected visual acuity (BCVA) was 6/6 in both eyes (OU). On examination, sectoral inferotemporal anterior scleritis (AS) with subclinical inferior RRD with peripheral holes in the lattice at the 6 o'clock position was noted. There was no posterior vitreous detachment. Optical coherence tomography (OCT) delineated the RRD objectively and was non-progressive for nine months. Barricade laser was given, in addition to intravenous methylprednisolone (IVMP), followed by a tapering dose of oral prednisolone and topical dexamethasone 0.1% over three months. Over a year, the scleritis resolved. However, six months later, while still on immunomodulating agents, the inferior RRD progressed on OCT. Segmental scleral buckle, indirect laser retinopexy, and subtenon triamcinolone injection were performed. IVMP 1 g per day was given for three days prior to surgery. Two months later, his BCVA was 6/6, with signs of fluid resorption and normal intraocular pressure. No recurrent AS was seen. Treatment of non-progressive, subclinical RRD patients with UC and active AS can be delayed with regular follow-up. When RRD progressed and there was no AS activity, it was the window of opportunity for the success of scleral buckle and perioperative steroids.

Rheumatoid arthritis-associated peripheral ulcerative keratitis outcomes after early immunosuppressive therapy

BACKGROUND/AIMS

To evaluate the role of early immunosuppressive therapy (IMT) in the management of rheumatoid arthritis (RA)-associated peripheral ulcerative keratitis (PUK).

METHODS

Single-centre, retrospective, comparative cohort study. Patients with RA-associated PUK were divided into two groups; those exposed to and those not exposed to early IMT, defined as administrating therapy within the first 4 weeks from the PUK onset. Outcomes included PUK recurrence, control of inflammation and development of ocular complications, including corneal scarring and perforation, cataract formation or progression and permanent visual loss.

RESULTS

A total of 52 eyes from 36 patients were included for analysis; 37 (71.2%) eyes received early IMT and 15 (28.8%) eyes did not. Follow-up time was 41.2+53.3 months (range: 4-236 months). While early IMT was a protective factor (HR 0.345, 95% CI 0.126 to 0.946, p=0.039), late RA diagnosis after PUK onset (HR 4.93, 95% CI 1.75 to 13.85, p=0.002) and retarded (≥2 months) control of inflammation (HR 8.37, 95% CI 1.88 to 37.16, p=0.005) were risk factors for PUK recurrence. Late IMT (OR 7.75, 95% CI 2.00 to 29.99, p=0.003), an unknown diagnosis of RA at first visit (OR 4.14, 95% CI 1.15 to 14.91, p=0.030) and at least one PUK recurrence (OR 6.42, 95% CI 1.71 to 24.07, p=0.006) were risk factors for visual loss. Survival analysis rendered eyes exposed to early IMT a lower risk of PUK recurrence (p=0.039).

CONCLUSION

Eyes with RA-associated PUK exposed to early IMT were more likely to achieve earlier inflammatory control, fewer recurrences and had better visual outcomes.

Hyaluronic acid - PVA films for the simultaneous delivery of dexamethasone and levofloxacin to ocular tissues

Ocular drug delivery is challenging due to the poor drug penetration across ocular barriers and short retention time of the formulation at the application site. Films, applied as inserts or implants, can be used to increase residence time while controlling drug release. In this work, hydrophilic films made of hyaluronic acid and two kinds of PVA were loaded with dexamethasone (included as hydroxypropylcyclodextrin complex) and levofloxacin. This association represents one of the main treatments for the post cataract surgery management, and it is also promising for eye infections whith pain and inflammation. Films were characterized in terms of swelling and drug release and were then applied to porcine eye bulbs and isolated ocular tissues. Film swelling leads to the formation of either a gel (3D swelling) or a larger film (2D swelling) depending on the type of PVA used. Films, prepared in an easy and scalable method, demonstrated high loading capacity, controlled drug release and the capability to deliver dexamethasone and levofloxacin to the cornea and across the sclera, to potentially target also the posterior eye segment. Overall, this device can be considered a multipurpose delivery platform intended for the concomitant release of lipophilic and hydrophilic drugs.

Pediatric Scleritis: An Update

Posterior idiopathic scleritis is the most common type of scleritis observed in childhood. Nevertheless, anterior and even necrotizing inflammatory scleritis may occur as well. Although less frequently than in the adult population, scleral inflammation can be associated with systemic disorders, which should be promptly recognized and treated to avoid both ocular and systemic complications. Hence, a multidisciplinary diagnostic work-up should be performed to rule out primarily infectious and autoimmune causes, such as viral and bacterial infections, anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis, pediatric sarcoidosis, Behçet's disease and HLA-B27-associated diseases. Treatment of scleritis should aim to control ocular inflammation, relieve symptoms and prevent relapses, to avoid complications, preserve visual acuity and improve the child's quality of life. It should be tailored to the patient, considering the type and severity of scleritis, the possible identification of an infectious cause or the presence of an associated rheumatologic condition.

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.

Ocular involvement and complications of lichen planus, lichen planus pigmentosus, and lichen planopilaris: A comprehensive review

Ocular involvement of lichenoid dermatoses, such as lichen planus (LP), lichen planus pigmentosus (LPP), and lichen planopilaris (LPL), although uncommon, is associated with skin manifestations. Isolated ocular involvement is very rare. When lesions are confined to the skin, the dermatologist inquires and evaluates for oral and genital symptoms and lesions, respectively; hence, eye manifestations are commonly neglected by the non-ophthalmologist. Ocular involvement in LP, LPP, and LPL may result in significant morbidity. An ophthalmic interrogatory and a gross ophthalmic evaluation performed by the dermatologist may unravel ocular signs and symptoms that require evaluation by an eye specialist. Ocular surface inflammation and scarring, when untreated, results in serious complications such as corneal perforation and permanent vision loss. This review aims to present an up-to-date overview for the dermatologist of the ocular involvement and complications of LP, LPP, and LPL, and when to refer to the ophthalmologist to prevent blinding complications.

Biologic Therapies and Small Molecules for the Management of Non-Infectious Scleritis: A Narrative Review

Scleritis refers to a wide spectrum of ocular conditions ranging from mild to sight-threatening scleral inflammation that may compromise visual function and threaten the anatomical integrity of the ocular globe. Most aggressive forms like necrotizing or posterior scleritis are often difficult-to-treat cases, refractory to conventional treatment. The association with systemic diseases, namely rheumatoid arthritis, Sjögren syndrome, granulomatosis with polyangiitis, and relapsing polychondritis, may have prognostic implications as well. A better understanding of the pathogenesis of ocular inflammatory diseases have paved the way to more effective and targeted treatment approaches. In this regard, a growing body of evidence supports the potential role of biologic agents in the management of non-infectious scleral inflammation, either idiopathic or in a background of immune-mediated systemic disorders. Biologic agents such as anti-tumor necrosis factor agents, interleukin-1 and interleukin-6 inhibitors as well as CD20 blockade have displayed promising results. More specifically, several studies have reported their ability to control scleral inflammation, reduce the overall scleritis relapses, and allow a glucocorticoid-sparing effect while being generally well tolerated. Anecdotal reports have also been described with other biologic agents including abatacept, ustekinumab, daclizumab, and alemtuzumab as well as targeted small molecules such as tofacitinib. Further studies are warranted to fully elucidate the role of biologic agents in non-infectious scleritis and investigate specific areas with the aim to administer treatments in the context of personalized medicine. This review summarizes the available data regarding clinical trials, small pilot studies, and real-life experience of the last two decades reporting the use of biologic agents in the management of non-infectious scleritis.

Case Report: Subconjunctival Triamcinolone Acetate-associated Scleral Necrosis: Is It Really Obsolete?

SIGNIFICANCE

Recent studies have established the safety of subconjunctival steroids for anterior scleritis, refuting scleral necrosis as a potential complication. However, presently, we report a rare case of scleral necrosis associated with subconjunctival triamcinolone acetate.

PURPOSE

The purpose of this study was to report a case of scleral necrosis after subconjunctival triamcinolone acetate administration for nonresponsive anterior nodular scleritis.

CASE REPORT

A 45-year-old man diagnosed with nodular anterior scleritis was administered subconjunctival triamcinolone acetate (4 mg) adjacent to the nodule after noting nonresponse for 4 months. Worsening of congestion was noted 3 weeks after the injection. Slit-lamp examination revealed diffuse congestion, 10 clock hours of anterior scleral necrosis, superior whitish depot of subconjunctival triamcinolone acetate, anterior segment flare, and few posterior synechiae. Ultrasound biomicroscopic imaging and contrast-enhanced computerized tomography showed a localized outpouching of sclera and buckling of anterior scleral wall superiorly. The result of the comprehensive blood profile and systemic evaluation undertaken to rule out any underlying autoimmune disorders and herpes zoster ophthalmicus was found negative. A diagnosis of subconjunctival triamcinolone acetate-associated scleral necrosis was made, and the patient was managed conservatively. Gradual improvement with dissolution of subconjunctival triamcinolone acetate and no recurrences till 2 years of follow-up were noted.

CONCLUSIONS

Scleral necrosis is a potential complication of subconjunctival triamcinolone acetate. Judicious and cautious use of subconjunctival triamcinolone acetate is advocated for nonresolving anterior scleritis.

Epidemiology of Scleritis in the United Kingdom From 1997 to 2018: Population-Based Analysis of 11 Million Patients and Association Between Scleritis and Infectious and Immune-Mediated Inflammatory Disease

OBJECTIVE

To estimate 22-year trends in the prevalence and incidence of scleritis, and the associations of scleritis with infectious and immune-mediated inflammatory diseases (I-IMIDs) in the UK.

METHODS

The retrospective cross-sectional and population cohort study (1997-2018) included 10,939,823 patients (2,946 incident scleritis cases) in The Health Improvement Network, a nationally representative primary care records database. The case-control and matched cohort study (1995-2019) included 3,005 incident scleritis cases and 12,020 control patients matched by age, sex, region, and Townsend deprivation index. Data were analyzed using multivariable Poisson regression, multivariable logistic regression, and Cox proportional hazards multivariable models adjusted for age, sex, Townsend deprivation index, race/ethnicity, smoking status, nation within the UK, and body mass index. Incidence rate ratios (IRRs) and 95% confidence intervals (95% CIs) were calculated.

RESULTS

Scleritis incidence rates per 100,000 person-years declined from 4.23 (95% CI 2.16-6.31) to 2.79 (95% CI 2.19-3.39) between 1997 and 2018. The prevalence of scleritis per 100,000 person-years was 93.62 (95% CI 90.17-97.07) in 2018 (61,650 UK patients). Among 2,946 patients with incident scleritis, 1,831 (62.2%) were female, the mean ± SD age was 44.9 ± 17.6 years (range 1-93), and 1,257 (88.8%) were White. Higher risk of incident scleritis was associated with female sex (adjusted IRR 1.53 [95% CI 1.43-1.66], P < 0.001), Black race/ethnicity (adjusted IRR 1.52 [95% CI 1.14-2.01], P = 0.004 compared to White race/ethnicity), or South Asian race/ethnicity (adjusted IRR 1.50 [95% CI 1.19-1.90], P < 0.001 compared to White race/ethnicity), and older age (peak adjusted IRR 4.95 [95% CI 3.99-6.14], P < 0.001 for patients ages 51-60 years versus those ages ≤10 years). Compared to controls, scleritis patients had a 2-fold increased risk of a prior I-IMID diagnosis (17 I-IMIDs, P < 0.001) and significantly increased risk of subsequent diagnosis (13 I-IMIDs). The I-IMIDs most strongly associated with scleritis included granulomatosis with polyangiitis, Behçet's disease, and Sjögren's syndrome.

CONCLUSION

From 1997 through 2018, the UK incidence of scleritis declined from 4.23 to 2.79/100,000 person-years. Incident scleritis was associated with 19 I-IMIDs, providing data for rational investigation and cross-specialty engagement.

Scleritis and sclerokeratitis associated with IgA vasculitis: A case series

Purpose

To describe a case series of scleritis associated with IgA vasculitis (IgAV) at a tertiary referral center.

Observations

Three men with scleritis associated with IgAV were identified: one with anterior scleritis alone, one with anterior scleritis and peripheral ulcerative keratitis (sclerokeratitis), and one with anterior and posterior scleritis. Visual acuity was preserved except from the patient who developed posterior scleritis. Ocular pain was the main symptom at presentation. All patients had a previous history of palpable purpura, but only one was aware of his underlying IgAV. Laboratory results revealed microhematuria and proteinuria with normal urinary β₂ microglobulin levels and negative serum ANCAs. Skin or kidney biopsy demonstrated leukocytoclastic vasculitis or glomerulonephritis with dominant IgA immune deposits.

Conclusions and Importance

Although uncommon, IgAV should be included in the differential diagnosis of anterior scleritis alone or associated with peripheral ulcerative keratitis or posterior scleritis, even in systemically asymptomatic patients. Urinalysis should not be underestimated in assessment of scleritis to detect early stages of glomerular disease. Scleritis may be the first manifestation whose study may lead to the diagnosis of IgAV. Multidisciplinary approach is necessary to prevent irreversible organ damage such as renal failure.

Tarsoconjunctival 'Hughes' flap for repair of globe perforation: A modified technique in the management of severe scleral necrosis

We report an unusual case of scleral and lid necrosis from suspected self-harm and the management of the resultant scleral perforation with a tarsoconjunctival 'Hughes' flap. To our knowledge, no previous literature describes such a technique in the repair of toxic scleral melts. Our case describes an alternative use for a Hughes flap in providing tectonic support and helping to restore the integrity of the globe in a complex case where conventional methods of 'patching' had failed.

The clinical and pathogenic spectrum of surgically-induced scleral necrosis: A review

The onset of scleral necrosis after ocular surgery may have catastrophic ocular and systemic consequences. The two most frequent surgeries causing surgically-induced scleral necrosis (SISN) are pterygium excision and cataract extraction. Several pathogenic mechanisms are involved in surgically induced scleral necrosis. All of them are poorly understood. Ocular trauma increasing lytic action of collagenases with subsequent collagen degradation, vascular disruption leading to local ischemia, and immune complex deposition activating the complement system represents some of the events that lead to scleral necrosis. The complex cascade of events involving different pathogenic mechanisms and the patient's abnormal immune response frequently leads to delayed wound healing that predisposes the development of scleral necrosis. The management of SISN ranges from short-term systemic anti-inflammatory drugs to aggressive immunosuppressive therapy and surgical repair. Therefore, before performing any ocular surgery involving the sclera, a thorough ophthalmic and systemic evaluation must be done to identify high-risk patients that may develop SISN.

Measurements of scleral thickness and corneal optic densitometry in patients with systemic lupus erythematosus

BACKGROUND

This study aimed to evaluate the scleral thickness and corneal parameters of patients with systemic lupus erythematosus (SLE).

METHODS

Forty-seven eyes of 47 SLE patients and 44 eyes of healthy controls were included in this cross-sectional study. Anterior segment optical coherence tomography (AS-OCT) was used to measure the corneal and scleral thickness. Scleral thickness (ST) was measured based upon the segmentation at 1000 to 5000 μm from the scleral spur. Pentacam HR was used to measure corneal parameters.

RESULTS

There was no statistically significant difference between SLE group and control group according to age and sex (P > .05). The ST measurements at all distances from scleral spur were found to be thicker in patients with SLE (P < .05). Central corneal thickness (CCT), cornea volume (CV), corneal densitometry (CD), and peripheral corneal thickness (PCT) measurements were similar between the groups (P > .05).

CONCLUSION

ST was thicker in SLE patients compared with healthy controls. AS-OCT seems helpful in selecting optimal sites for pharmaceutical or surgical intervention in SLE patients, since it shows thickness variations in anterior sclera.

Current insights in the pathogenesis of scleritis

Scleritis is a sight-threatening inflammation characterized by severe pain and redness of the eye. It can cause blindness by severe complications like scleral and corneal necrosis, keratitis, and uveitis. The pathogenesis of scleritis is largely unknown due to a combination of the rarity of the disease, the little available human tissue-based research material, and the lack of animal models. The immune system is assumed to play a crucial role in the pathogenesis of scleritis. Multiple clues indicate probable antigenic stimuli in scleritis, and the involvement of matrix metalloproteinases in the destruction of scleral tissue. In this article we review the current insights into the pathogenesis of scleritis, and we suggest new hypotheses by implementing knowledge of systemic autoimmune disease pathogenesis. Understanding the pathogenesis of scleritis is crucial to improve the clinical management, as well as to find novel treatment modalities.

More Than Meets the Eye: A Rare Case of Posterior Scleritis Masquerading as Orbital Cellulitis

Posterior scleritis is a rare sight-threatening condition that typically presents with an acutely painful eye, often with associated reduced visual acuity. Diagnosis can be challenging and requires specialist ophthalmological assessment. Consequences of delayed treatment include permanent loss of vision. We present a case of posterior scleritis initially managed as periorbital cellulitis. We highlight the importance of broad differential diagnoses when assessing painful periorbital swelling, and present a review of current management strategies for posterior scleritis.

Optimization and Characterization of Aqueous Micellar Formulations for Ocular Delivery of an Antifungal Drug, Posaconazole

Background:

Topical therapy is preferred for the management of ocular fungal infections due to its superiorities which include overcoming potential systemic side effects risk of drugs, and targeting of drugs to the site of disease. However, the optimization of effective ocular formulations has always been a major challenge due to restrictions of ocular barriers and physiological conditions. Posaconazole, an antifungal and highly lipophilic agent with broad-spectrum, has been used topically as off-label in the treatment of ocular fungal infections due to its highly lipophilic character. Micellar carriers have the potential to improve the solubility of lipophilic drugs and, overcome ocular barriers.

Objective:

In the current study, it was aimed optimization of posaconazole loaded micellar formulations to improve aqueous solubility of posaconazole and to characterize the formulations and to investigate the physical stability of these formulations at room temperature (25°C, 60% RH), and accelerated stability (40°C, 75% RH) conditions.

Method:

Micelles were prepared using a thin-film hydration method. Pre-formulation studies were firstly performed to optimize polymer/surfactant type and to determine their concentration in the formulations. Then, particle size, size distribution, and zeta potential of the micellar formulations were measured by ZetaSizer Nano-ZS. The drug encapsulation efficiency of the micelles was quantified by HPLC. The morphology of the micelles was depicted by AFM. The stability of optimized micelles was evaluated in terms of particle size, size distribution, zeta potential, drug amount and pH for 180 days. In vitro release studies were performed using Franz diffusion cells.

Results:

Pre-formulation studies indicated that single D-ɑ-tocopheryl polyethylene glycol succinate (TPGS), a combination of it and Pluronic F127/Pluronic F68 are capable of formation of posaconazole loaded micelles at specific concentrations. Optimized micelles with high encapsulation efficiency were less than 20 nm, approximately neutral, stable, and in aspherical shape. Additionally, in vitro release data showed that the release of posaconazole from the micelles was higher than that of suspension.

Conclusion:

The results revealed that the optimized micellar formulation of posaconazole offers a potential approach for topical ocular administration.

Ocular nonsteroidal inflammatory drugs: where do we stand today?

Since their first introduction in ophthalmology, the use of NSAIDs (nonsteroidal anti-inflammatory drugs) has been exponentially expanded, with numerous therapeutic applications. Despite their controversial history, they have proven their efficacy as anti-inflammatory agents in a variety of diseases. Nowadays, NSAIDs are part of surgical protocols of the most commonly performed ophthalmic operations, such as cataract or ocular surgery. They are universally implicated in the management of conjunctivitis, retinal and choroidal disease and miscellaneous inflammatory diseases. Moreover, although linked with serious adverse events and toxicities, their therapeutic magnitude in Ophthalmology should not be affected. This review systematically portrays the variety of ocular NSAIDs available to date, along with their differences in their way of action, indications and potential side effects in various ophthalmologic conditions.

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.

Potential for endocannabinoid system modulation in ocular pain and inflammation: filling the gaps in current pharmacological options

Challenges in the management of ocular pain are an underappreciated topic. Currently available therapeutics lack both efficacy and clear guidelines for their use, with many also possessing unacceptable side effects. Promising novel agents would offer analgesic, anti-inflammatory, and possibly neuroprotective actions; have favorable ocular safety profiles; and show potential in managing neuropathic pain. Growing evidence supports a link between the endocannabinoid system (ECS) and a range of physiological and disease processes, notably those involving inflammation and pain. Both preclinical and clinical data suggest analgesic and anti-inflammatory actions of cannabinoids and ECS-modifying drugs in chronic pain conditions, including those of neuropathic origin. This review will examine existing evidence for the anatomical and physiological basis of ocular pain, specifically, ocular surface disease and the development of chronic ocular pain. The mechanism of action, efficacy, and limitations of currently available treatments will be discussed, and current knowledge related to ECS-modulation of ocular pain and inflammatory disease will be summarized. A perspective will be provided on the future directions of ECS research in terms of developing cannabinoid therapeutics for ocular pain.

[Scleritis and systemic diseases: What should know the internist?]

Scleritis is an inflammatory disease of the sclera; outer tunic of the eye on which the oculomotor muscles are inserted. It can be associated with a systemic disease up to one time out of 3. These associated diseases are mainly rheumatoid arthritis, vasculitis, including granulomatosis with polyangiitis in the first line and spondyloarthropathies. Before mentioning such an etiology, it is necessary to eliminate an infectious cause, mainly herpetic, which is regularly underestimated. The classification of scleritis is clinical. We distinguish between anterior scleritis and posterior scleritis. Anterior scleritis is diffuse or nodular, usually of good prognosis. Anterior necrotizing scleritis with inflammation is often associated with an autoimmune disease, necrotizing scleritis without inflammation usually reflects advanced rheumatoid arthritis. The treatment of these conditions requires close collaboration between internists and ophthalmologists to decide on the use of corticosteroid therapy with or without immunosuppressors or biotherapies.

Ocular Emergencies: Red Eye

"Red eye" is used as a general term to describe irritated or bloodshot eyes. It is a recognizable sign of an acute/chronic, localized/systemic underlying inflammatory condition. Conjunctival injection is most commonly caused by dryness, allergy, visual fatigue, contact lens overwear, and local infections. In some instances, red eye can represent a true ocular emergency that should be treated by an ophthalmologist. A comprehensive assessment of red eye conditions is required to preserve the patients visual function. Severe ocular pain, significant photophobia, decreased vision, and history of ocular trauma are warning signs demanding immediate ophthalmological consultation.

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.

Clinical Features and Complications of Scleritis in Chinese Patients

PURPOSE

To characterize the clinical features of scleritis in Chinese patients.

METHODS

The history, demographics, ocular findings, auxiliary examination findings, complications, systemic diseases and therapeutic effects were analyzed retrospectively.

RESULTS

The study included 124 male and 169 female patients with scleritis. Anterior and posterior scleritis were, respectively, found in 243 and 42 patients. The other eight patients had both anterior and posterior involvement. The mean age of scleritis onset was 39.4 years. Systemic diseases associated with scleritis mainly included rheumatoid arthritis (RA) (4.4%), ankylosing spondylitis (AS) (3.4%), and tuberculosis (1.7%). Anterior uveitis (23.7%), complicated cataract (16.7%), and intraocular hypertension (12.6%) were common complications of scleritis. Scleritis was controlled in 94.6% of the patients treated with corticosteroids combined with immunosuppressive agents.

CONCLUSIONS

Diffuse anterior scleritis was the most common scleritis entity in China. RA and AS were relatively common diseases associated with scleritis. Corticosteroids combined with immunosuppressive agents effectively controlled the disease.

Rituximab in the Treatment of Refractory Noninfectious Scleritis

PURPOSE

To describe the outcomes of the use of rituximab in the treatment of refractory noninfectious scleritis.

DESIGN

Retrospective case series.

METHODS

Review of the medical charts of patients with noninfectious scleritis refractory to conventional immunomodulatory therapy who were seen at the Massachusetts Eye Research and Surgery Institution between 2005 and 2015. The primary outcome measure in this study was steroid-free remission. Secondary outcomes were favorable response (decrease in scleritis activity score) and decrease in steroid dependence.

RESULTS

There were 15 patients, with a mean follow-up duration of 34 months. Fourteen patients (93.3%) showed a clinical improvement, with 13 (86.6%) achieving a scleritis activity score of zero at 6 months. To date, 2 patients continue to enjoy durable drug-free remission (28 and 32 months follow-up). There was only 1 adverse effect recorded (infusion hypotension) requiring cessation of rituximab.

CONCLUSION

Rituximab can be an effective treatment modality for recalcitrant noninfectious scleritis and, in some, can result in long-term durable drug-free remission.

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.

Uveitis

Multidisciplinary management in the diagnosis and management of patients with ocular inflammatory disease is often critical. The workup of uveitis or scleritis may reveal an underlying systemic disease. Recognition of inflammation by the primary care physician can facilitate prompt referral to a uveitis specialist and improve patient outcomes. The primary care physician can assist the ophthalmologist in monitoring for potential side effects of corticosteroids and immunosuppressive drugs, including the newer biologic agents. The ophthalmologist in turn can assist the primary care physician in recognizing that active uveitis may suggest incomplete control of preexisting conditions.