Posterior Scleritis: Analysis of Epidemiology, Clinical Factors, and Risk of Recurrence in a Cohort of 114 Patients

Scleritis and Development of Immune-Mediated Disease: A Retrospective Chart Review

OBJECTIVE

Scleritis may be idiopathic or caused by trauma, infections, or an immune-mediated disease (IMD). Our study aimed to understand the relationship between scleritis and IMD, including presenting characteristics, serologies, and treatment course. Understanding these associations may allow clinicians to risk-stratify patients and predict their clinical and treatment course.

METHODS

We conducted a retrospective chart review of 341 patients with scleritis seen at a tertiary care center between January 1, 2005, and December 31, 2020. Demographics, scleritis characteristics, treatment response, recurrence, and serologic data were compared among patients with idiopathic and IMD-associated scleritis.

RESULTS

Among patients with scleritis seen, 145 patients (43%) had an associated IMD, most commonly rheumatoid arthritis (RA; 39%), vasculitis (21%), or inflammatory bowel disease (14%). In most cases, the IMD diagnosis predated the scleritis presentation (63%), though vasculitis cases were more likely to develop during or after scleritis episodes. There were no significant differences in demographics or treatment failures among patients with scleritis with and without associated IMDs. Patients with IMDs were more likely to have a recurrence of scleritis (62% vs 49%, P = 0.02).

CONCLUSION

At our ophthalmology center, 43% of patients with scleritis had an associated IMD, and most patients with an IMD were symptomatic from this disease prior to scleritis presentation. RA was the most commonly associated condition and typically predated the scleritis, whereas vasculitis was more likely diagnosed during or after the scleritis episode. Scleritis among patients with IMD is more likely to recur compared to scleritis that is idiopathic.

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.

Posterior Scleritis: A Case Report and Literature Review of the Management of the Condition

Posterior scleritis is a rare inflammatory eye condition affecting the posterior segments of the sclera and is more prevalent in females. Its clinical presentation, often nonspecific, includes ocular pain, headache, and vision loss. Misdiagnosis is common due to a lack of specific symptoms posing a potential threat to vision. The etiology is often tied to rheumatic diseases, such as rheumatoid arthritis (RA), systemic erythematous lupus (SLE), and anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis. Posterior scleritis poses diagnostic challenges, mimicking many other ocular conditions, hence necessitating a thorough clinical eye exam. Laboratory studies, including inflammatory markers and markers of rheumatic diseases, may identify underlying systemic diseases. Imaging, including B-scan ultrasound and magnetic resonance imaging (MRI), aids in accurate diagnosis. Treatment involves non-steroidal anti-inflammatory drugs (NSAID), as well as topical corticosteroids for mild disease and systemic corticosteroids for severe disease. Biologic therapy has become increasingly significant for refractory cases. A multidisciplinary approach involving ophthalmology and rheumatology is crucial in the management of this potential sight-threatening disease. This case report highlights a 46-year-old woman with a history of RA-associated posterior scleritis.

Management of Scleritis in Older Adults

Scleritis, an inflammatory disease of the eye affecting scleral tissue, presents unique challenges in the older adult population. Unlike their younger counterparts, older individuals manifest a distinct spectrum of the disease with different underlying etiologies, co-morbidities, altered immune function, and an increased risk of systemic side effects from medication choices. Addressing these complexities necessitates a comprehensive and multidisciplinary approach. Treatment of choice will depend on any underlying cause but generally involves non-steroidal anti-inflammatory drugs, systemic or local corticosteroids, and potentially disease-modifying anti-rheumatic drugs. Utilization of these therapeutic agents in older adults warrants careful consideration because of their potential side-effect profiles. This article critically examines the specific concerns for the use of these drugs in older patients and reviews the existing literature on their use in this specific cohort.

A case of granulomatosis with polyangiitis-associated scleritis presenting as conjunctivitis

A 42-year-old male presented initially with conjunctivitis and was treated with topical medical medications without any improvement. He developed ocular pain subsequently and further examination revealed lid edema, conjunctival hyperemia with chemosis, matting of lashes with yellowish discharge, and deeper episcleral congestion which did not blanch with topical vasoconstrictor. Subsequent laboratory investigation revealed positive cytoplasmic-antineutrophil cytoplasmic antibody (Anti-PR 3 antibody). He continued to develop recurrences and finally responded to oral azathioprine. Granulomatosis with polyangitis may rarely present as conjunctivitis and subsequently manifest as scleritis.

Fungal panophthalmitis presenting as severe posterior scleritis

Purpose

To report a highly unusual and fulminant case of infectious fungal panophthalmitis that initially presented as angle closure in the setting of posterior scleritis, culminating in the loss of the affected eye.

Observations

A 57-year-old woman with a history of poorly controlled diabetes mellitus and autoimmune disease presented with a unilateral flat anterior chamber, highly elevated intraocular pressure (50-65 mmHg) and severe chemosis of the right eye. Initial VA was NLP in the affected eye. An ultrasound B-scan revealed a very pronounced T-sign and severely thickened posterior sclera and choroid indicative of posterior scleritis. Bloodwork showed elevation of WBC count to 18 K/μL and broad spectrum antibiotics were initiated. However, a comprehensive infectious workup including fungal cultures were persistently negative. After three days of IV NSAIDs and antibiotics, WBC count normalized and pain had mildly improved. After consultation with a multidisciplinary team that included the Glaucoma, Retina/Uveitis, Infectious Disease, Rheumatology and Internal Medicine services, high dose IV methylprednisolone was started. Despite the initial improvement, corneoscleral decompensation and paralimbal perforation of the globe occurred. The eye was enucleated, and pathologic examination revealed a dense focus of budding yeast in the vitreous cavity.

Conclusions and importance

Scleritis is a rare entity, with posterior scleritis, infectious scleritis, and fungal scleritis representing increasingly rare subtypes. However, fungal scleritis may be underdiagnosed due to a number of factors including culture negativity, a lack of clinical suspicion, as well as the disease's propensity to masquerade as other pathologies such as angle closure or malignant glaucoma. Fungal scleritis should be considered in cases that present with possible infectious etiology, worsen with systemic corticosteroid treatment, or worsen despite broad-spectrum antibiotic coverage. When treating patients with underlying risk factors such as uncontrolled diabetes mellitus, recent antibiotic use, use of total parenteral nutrition, or immunosuppression, a higher level of suspicion for fungal etiology is also appropriate. In the outpatient setting, fungal eye infections do not always present with critical systemic illness or culture positivity. If there is suspicion for fungal involvement, early aqueous or vitreous tap may improve diagnostic yield.

[Scleritis and episcleritis]

Scleritis and episcleritis are rare ocular inflammatory diseases but deserve to be known by internists because of their frequent association with systemic autoimmune diseases. It is important to distinguish them between because their prognosis, therapeutic management and potential complications are very different. Episcleritis represents a superficial ocular inflammation with usually benign visual prognosis, no complication with local treatment, and is associated with a systemic autoimmune disease in rare cases. In contrast, scleritis is a potentially serious ophthalmological condition that can threaten the visual prognosis in the absence of appropriate systemic treatment. It is associated with an underlying disease in 40-50% of cases, in particular a systemic autoimmune disease (25-35% of cases) or an infectious cause (5-10% of cases). Rheumatoid arthritis and systemic vasculitides, particularly antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides, are the main autoimmune causes of scleritis and episcleritis. Scleritis can reveal the underlying autoimmune disease and requires systematic etiological investigations. Aggressive, complicated, refractory forms or those associated with a systemic autoimmune disease require glucocorticoids or even immunosuppressants, and close collaboration between ophthalmologists and internists is required. The development of biologic agents offers new effective therapeutic tools in the management of these difficult cases.

Clinical Features, Treatment, and Visual Outcomes of Posterior Scleritis from Tertiary Eye Care Center

PURPOSE

To describe the epidemiological and clinical features and course of patients with posterior scleritis (PS).

METHODS

This retrospective, cross-sectional consecutive case series analyzed the medical records of 16 patients diagnosed with PS.

RESULTS

Female gender and unilateral involvement were dominant. Blurred vision (84.21%) and ocular pain (78.95%) were the most common presenting complaints. Serous retinal detachment was the most common ocular finding (84.21%), followed by optic disc swelling (42.11%). Increased scleral thickness was observed in all patients, although a T-sign was detected 8 of 19 eyes (42.1%). Recurrence occured in 5 of 19 eyes in mean 30.2 ± 34.7 months. Central macular thickness, choroidal thickness, and retinal nerve fiber layer thickness were reduced with treatment at final examination significantly (p = .005, .002, and .002, respectively).

CONCLUSIONS

PS should be considered in patients presenting with unilateral ocular pain and decreased vision. Not only USG findings but also OCT findings are very useful in the follow-up of treatment response.

Characterization of patients with ocular pain evaluated with ultrasound

BACKGROUND

The cause of ocular pain in the quiet eye is challenging to diagnose. It is a common complaint in the ophthalmology clinic and there are no actual guidelines on the exams that should be ordered initially. We decided to characterize patients with eye pain and normal ophthalmological examination who underwent ocular ultrasound, their findings, and systemic work-up.

METHODS

A retrospective chart review of patients who underwent ocular ultrasound due to ocular pain and no clinical findings on initial slit-lamp examination. We evaluated patient characteristics and analyzed systemic work-up results in contrast to ocular ultrasound findings.

RESULTS

Two hundred and three patients with normal slit-lamp examination and ocular pain were evaluated using ocular ultrasound at Clinica Barraquer. Most of the patients were women (88.7%), and 55% were older than 50 years. Nearly all of the patients had echographic findings, 87.7% of patients showed evidence of scleral scars, from which 66.5% had signs of activity, and 42.9% had thickened extraocular muscles. In general, most patients with ocular pain had normal results on systemic work-up, but the patients who did have positive results tended to have echographic findings.

CONCLUSION

Posterior inflammation is present in most patients with ocular pain in a quiet eye, and echography is an optimal tool to identify this. There is a tendency towards abnormal autoimmune test results and echographic findings. This should be considered in the initial work-up of these patients, given the importance of early diagnosis and the threat of vision loss with severe inflammation.

Comprehensive profiling of extracellular vesicles in uveitis and scleritis enables biomarker discovery and mechanism exploration

BACKGROUND

Uveitis and posterior scleritis are sight-threatening diseases with undefined pathogenesis and accurate diagnosis remains challenging.

METHODS

Two plasma-derived extracellular vesicle (EV) subpopulations, small and large EVs, obtained from patients with ankylosing spondylitis-related uveitis, Behcet's disease uveitis, Vogt-Koyanagi-Harada syndrome, and posterior scleritis were subjected to proteomics analysis alongside plasma using SWATH-MS. A comprehensive bioinformatics analysis was performed on the proteomic profiles of sEVs, lEVs, and plasma. Candidate biomarkers were validated in a new cohort using ELISA. Pearson correlation analysis was performed to analyze the relationship between clinical parameters and proteomic data. Connectivity map database was used to predict therapeutic agents.

RESULTS

In total, 3,668 proteins were identified and over 3000 proteins were quantified from 278 samples. When comparing diseased group to healthy control, the proteomic profiles of the two EV subgroups were more correlated with disease than plasma. Comprehensive bioinformatics analysis highlighted potential pathogenic mechanisms for these diseases. Potential biomarker panels for four diseases were identified and validated. We found a negative correlation between plasma endothelin-converting enzyme 1 level and mean retinal thickness. Potential therapeutic drugs were proposed, and their targets were identified.

CONCLUSIONS

This study provides a proteomic landscape of plasma and EVs involved in ankylosing spondylitis-related uveitis, Behcet's disease uveitis, Vogt-Koyanagi-Harada syndrome, and posterior scleritis, offers insights into disease pathogenesis, identifies valuable biomarker candidates, and proposes promising therapeutic agents.

Visual Morbidity and Outcomes of Scleritis Associated with Intraocular Inflammation Compared to Isolated Scleritis

PURPOSE

To compare visual outcomes, ocular complications and therapies for patients with scleritis-associated intraocular inflammation (SAI) and patients with isolated scleritis (IS).

RESULTS

A total of 52 patients (36 with SAI and 16 with IS) were reviewed. Mean age (standard deviation) at presentation was 48.4 years old (± 15.4) in the SAI group and 53 years old (± 17.1) in the IS group (p = .37). Visual acuity was worse at presentation and last visit for patients with SAI compared to IS (p = .04). Patients in the SAI group developed greater posterior segment complications than in the IS group (p = .002).

CONCLUSIONS

Scleritis with intraocular inflammation was associated with a higher rate of visual morbidity compared to isolated scleritis. More aggressive management strategies may be needed for patients who present with scleritis associated with inflammation.

Bilateral posterior scleritis due to giant cell arteritis

A woman aged mid 70s with mild learning difficulty presented with eye symptoms, headache and shoulder pains. She was found to have bilateral posterior scleritis secondary to giant cell arteritis. Posterior scleritis is a potentially blinding condition, with ambiguous symptoms and signs, therefore diagnosis is commonly delayed. This patient was seen in General Practice as well as in Accident and Emergency, where diagnoses of acute angle closure glaucoma as well as iritis were rightfully considered. Her symptoms persisted for 11 days before ophthalmic opinion was sought. Thorough assessment of a painful red eye as well as knowledge of these red-flag signs may allow early treatment and a better outcome for patients. The Royal College of Ophthalmologists has published guidance on how to assess and manage visual loss in people with learning difficulties, including recognising 'symptoms' such as hesitancy on steps, eye rubbing and loss of interest in activities.

Surgically induced diffuse scleritis associated with choroidal detachment following phacoemulsification surgery

PURPOSE

We present a case of a hemorrhagic choroidal detachment associated with a surgical induced diffuse scleritis (SIDS) following phacoemulsification surgery.

CASE REPORT

A-49-year-old healthy male with history of high myopia and pars-plana vitrectomy associated with 360° encircling buckle surgery years ago, who underwent phacoemulsification surgery with in-the-bag intraocular lens implantation on the right eye and developed an important 360° hemorrhagic choroidal detachment on the first-day post-surgery, 10 days later, presented SIDS. First day after surgery, best-corrected visual acuity was hands movement in the affected eye. Ten days later, the patient presented with severe ocular pain and redness on the right eye, the right sclera showed active diffuse inflammation without thinning. A normal collagen vascular profile was found and systemic vasculitic disorders were discarded. The patient responded well to systemic therapy (oral prednisone, 0.5 mg/kg/day at the beginning and then 1 mg/kg/day when scleritis appeared) and 8 weeks later, fundus examination revealed complete resolution of the hemorrhagic choroidal detachment and inflammation.

CONCLUSION

A rare presentation of a surgical induced diffuse scleritis associated with choroidal detachment as an acute complication due to phacoemulsification cataract surgery was presented. Early recognition and treatment led to visual improvement and resolution of the scleritis and choroidal detachment.

Ocular manifestations of rheumatoid arthritis

PURPOSE OF REVIEW

This article summarizes the pathophysiology of rheumatoid arthritis and common ocular manifestations that it is associated with: keratoconjunctivitis sicca, episcleritis, scleritis, and peripheral ulcerative keratitis.

RECENT FINDINGS

Newer biologic agents are being used to effectively treat rheumatoid arthritis and its ocular manifestations.

SUMMARY

The eye is a frequent extra-articular site of inflammation in patients with rheumatoid arthritis. Ocular involvement can range from more benign conditions such as keratoconjunctivitis sicca and episcleritis, to potentially vision and globe-threatening diseases like scleritis and peripheral ulcerative keratitis. Clinicians should be aware of these ophthalmic manifestations and the various treatment options that are available. Coordination between ophthalmology and rheumatology is helpful in the treatment of these patients.

Outcomes of Escalating Immunosuppressive Treatments for Recalcitrant Noninfectious Posterior Scleritis

INTRODUCTION

This article aimed to summarize the outcomes of escalating immunosuppressive treatments for patients with recalcitrant noninfectious posterior scleritis (PS).

METHODS

Clinical records of 16 patients diagnosed with recalcitrant noninfectious PS in the Ocular Immunity and Uveitis Department of Zhongshan Ophthalmic Center from September 2016 to December 2021 were reviewed. Patients were treated with escalating immunosuppressive regimen including corticosteroid, immunosuppressants (IMTs), and adalimumab (ADA). Demographic characteristics and clinical findings at each visit were recorded. The doses of prednisone were analyzed. Main outcomes were corticosteroid-sparing effects, control of inflammation, visual acuity, and safety profile.

RESULTS

Ocular pain was the most common finding (100%), followed by the T sign on the B scan (93.8%) and associated anterior scleritis (75.0%). The average initial dose of prednisone was 25.0 mg/day, and tapered to 11.3 and 5.0 mg/day at month 1 and 3, respectively, with statistical significance (p < 0.05). The median overall periods of prednisone tapering to 10, 5, and 0 mg/day were 1.0, 3.0, and 3.0 months, respectively. There were 93.8% of patients receiving prednisone ≤ 10 mg/day and 68.8% of patients off prednisone at last visit. There were 80% of patients treated with IMT and ADA off prednisone at last visit, reaching the highest percentage compared with others. A best-corrected visual acuity of 1.0 or better at last visit was achieved in 10 eyes (62.5%). The escalating treatments showed good safety profile.

CONCLUSION

Patients of recalcitrant noninfectious PS benefited from escalating immunosuppressive treatments with favorable visual outcome, in which methotrexate, ciclosporin, and ADA were preferred with good safety.

Tofacitinib in Scleritis: A Case Series

PURPOSE

To report the use of tofacitinib in ten patients with scleritis where the traditional immunomodulation was not successful or could not be used.

METHOD

A retrospective chart review.

RESULT

Tofacitinib was successful in the treatment of scleritis in patients either recalcitrant to or intolerant to conventional therapy in 9 out of 10 cases reported here. Two patients had developed reactivation of herpetic infection after 1 month of starting tofacitinib. The duration from diagnosis of scleritis to the institution of tofacitinib therapy varied from 1 month to 60 months. Duration of follow-up varies from 2 months to 11 months.

CONCLUSION

Tofacitinib can be used as an important future option for managing recurrent and recalcitrant cases of scleritis.

Bilateral posterior scleritis after sequential bilateral cataract surgery: a case report

Background

Posterior scleritis is a rare, inflammatory ophthalmic disease, leading to severe visual impairment if untreated. Posterior scleritis occurring after surgery, unrelated to systemic inflammatory diseases, is even rarer. This report discusses a case of bilateral posterior scleritis, after cataract surgery in both the eyes, treated with high-dose steroids.

Case presentation

A 55-year-old man, who had undergone bilateral sequential cataract surgery one week before, presented with sudden loss of vision and ocular pain in both eyes. The patient had no systemic diseases or neurological symptoms. Serous retinal detachment of the macula with optic disc swelling was observed on fundus examination in both the eyes, and bilateral thickening of choroid and sclera was seen in ultrasonography. Under diagnosis of bilateral posterior scleritis due to the increased signal of sclera in both the eyes on magnetic resonance imaging, high-dose steroid therapy was performed. After treatment, improvement in visual acuity and retinal detachment were observed, and thereafter, it has been maintained without relapse.

Conclusions

With high-dose steroid therapy, we successfully treated a rare case of bilateral posterior scleritis following cataract surgery in both eyes. To our knowledge, this is the first report on posterior scleritis occurring after surgery, unrelated to systemic inflammatory diseases.

Clinical patterns and risk factors in scleritis: a multicentric study in Colombia

PURPOSE

This study aims to describe the clinical characteristics of scleritis in a large cohort of Colombian patients and identify factors associated with the clinical presentation.

METHODS

Retrospective case series of patients with scleritis from 2015 to 2020. Clinical records were obtained from seven uveitis referral centers in Colombia. Patients with a diagnosis of episcleritis were excluded.

RESULTS

We evaluated 389 patients with scleritis (509 eyes). There was a female predominance (75.6%) with a mean age of 51 ± 15 years. Most cases were noninfectious (94.8%) and unilateral (69.2%). The most frequent type of inflammation was diffuse anterior scleritis (41.7%), followed by nodular scleritis (31.9%) and necrotizing scleritis (12.3%). Systemic autoimmune diseases were found in 41.3% of patients, the most common being rheumatoid arthritis (18.5%) and granulomatosis with polyangiitis (5.9%). Polyautoimmunity was found in 10.4% of those with a systemic autoimmune disease. The most frequent treatment was systemic steroids (50.9%), followed by systemic NSAIDs (32.4%). Steroid-sparing immunosuppression was required in 49.1% of patients. Systemic autoimmune diseases were more common in patients with necrotizing scleritis and those older than 40 years of age. Best-corrected visual acuity of 20/80 or worse at presentation was more common in necrotizing scleritis and subjects with associated uveitis, ocular hypertension, or who were over 40 years of age.

CONCLUSIONS

This is the first study in Colombia and the largest in Latin America describing the clinical characteristics and presentation patterns of scleritis. The most common presentation was in females, with unilateral, anterior diffuse noninfectious scleritis. Systemic autoimmune diseases and polyautoimmunity were frequent, as was the need for steroid-sparing immunosuppression. Age over 40 and necrotizing scleritis were associated with higher odds of having a systemic autoimmune disease and worse visual acuity at presentation.

Scleritis in Lyme Disease

PURPOSE

To estimate the incidence of scleritis in Lyme disease and report clinical features.

DESIGN

Incidence rate estimate and case series.

METHODS

Data were collected from an electronic medical record on patients with scleritis presenting to the Wilmer Eye Institute between January 1, 2012 and December 31, 2020. A diagnosis of Lyme disease was made using the Infectious Diseases Society of America, American Academy of Neurology, and the American College of Rheumatology 2020 joint criteria plus a response to antibiotic therapy. After identifying all new-onset cases of scleritis in the database, the proportion of new-onset scleritis with Lyme disease was calculated. The proportion of Lyme disease cases with scleritis was estimated using the number of cases with Lyme disease from the Baltimore metropolitan area reported to the Centers for Disease Control and Prevention. After querying other major eye centers in the area for any cases of Lyme disease scleritis, none were identified, and the incidence of Lyme disease scleritis was estimated using published U.S. Census data for the greater Baltimore metropolitan area.

RESULTS

Six cases of Lyme disease scleritis were identified in the 8-year time frame; 1 additional case was identified in the following year. Lyme disease scleritis accounted for 0.6% of all cases of scleritis, and 0.052% of patients with Lyme disease had scleritis. The estimated incidence of Lyme scleritis was 0.2 per 1,000,000 population per year (95% confidence interval 0-0.4), whereas the estimated incidence of Lyme disease in the area was 3 per 10,000 population per year (95% confidence interval 2.9-3.1). All scleritis cases were anterior, unilateral, without necrosis, and resolved with antibiotic use without relapse in a median of 39.5 days (range 29-57 days). Other features of Lyme disease were present in 4 of 7 patients, including a history of erythema migrans in 2 of 7 patients.

CONCLUSIONS

Lyme disease is an uncommon cause of scleritis in endemic areas.

Management of noninfectious scleritis

Scleritis is a manifestation of inflammatory eye disease that involves the sclera. It can be divided into multiple subtypes, including diffuse anterior, nodular anterior, necrotizing, and posterior scleritis. In many cases, scleritis is restricted to the eye; however, it can occur in the context of systemic illness, particularly autoimmune and infectious conditions. Patients with autoimmune conditions, such as rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematosus, and polyangiitis with granulomatosis, may develop scleritis flares that may require topical and systemic therapy. Initial therapy typically involves oral nonsteroidal anti-inflammatory drugs (NSAIDs); however, it is important to address the underlying condition, particularly if systemic. Other treatment regimens typically involve either local or systemic steroids or the use of immunomodulatory agents, which have a wide range of efficacy and documented use in the literature. There is a myriad of immunomodulatory agents used in the treatment of scleritis including antimetabolites, calcineurin inhibitors, biologics, and alkylating agents. In this review, we highlight the various subtypes of noninfectious scleritis and explore each of the mainstay agents used in the management of this entity. We explore the use of steroids and NSAIDs in detail and discuss evidence for various immunomodulatory agents.

Immunopathological Analysis of a Mouse Model of Arthritis-Associated Scleritis and Implications for Molecular Targeted Therapy for Severe Scleritis

Scleritis involves inflammation of the sclera, which constitutes 75% of the wall of the eye. This pathology is often seen as an ocular lesion associated with systemic inflammatory diseases. Severe types of scleritis such as posterior scleritis require urgent immunosuppressive treatments, including molecularly targeted therapies to avoid permanent visual impairment. Which molecules should be selected as targets has remained unclear. To clarify the pathogenesis of scleritis and propose appropriate target molecules for therapy, we have established novel animal model of scleritis by modifying the Collagen-II Induced Arthritis (CIA) model. Immunization twice with collagen II emulsified with complete Freund's adjuvant (CFA) caused arthritis and scleritis. The clinical appearance resembled human diffuse scleritis. Histopathological analysis suggested that macrophages, plasma cells, deposition of immune complexes, and growth of blood and lymphatic vessels are involved in the pathogenesis of CIA-associated scleritis. In addition, we analysed the background diseases of posterior scleritis and responses to molecularly targeted therapies as a case series study. We inferred from both the animal model and case series study that targets should not be T cells, but factors inhibiting macrophage activity such as tumor necrosis factor (TNF) and interleukin (IL)-6, and molecules suppressing antibody-producing cells such as CD20 on B cells should be targeted by molecularly targeted therapies.

Choroidal involvement in non-infectious posterior scleritis

Purpose

To provide a comprehensive overview of choroidal involvement in non-infectious posterior scleritis; including different imaging modalities and their clinical usefulness.

Methods

Narrative review.

Results

Posterior scleritis is an uncommon yet potentially sight-threatening inflammation of the sclera. During the disease process, inflammation can spread to the adjacent choroid, causing different manifestations of choroidal involvement: (1) increased choroidal thickness, (2) choroidal vasculitis, (3) presentation as a choroidal or subretinal mass in nodular posterior scleritis, and (4) choroidal folds, choroidal effusion and exudative retinal detachment.

Conclusions

Clinical characteristics and multimodal imaging can aid in diagnosing and monitoring disease progression and response to treatment in non-infectious posterior scleritis with choroidal involvement.

Factors affecting the resolution of acute non-infectious anterior scleritis

BACKGROUND/AIMS

Tumor necrosis factor alpha (TNF-⍺) inhibitors are increasingly being used to treat scleritis, however, their efficacy has not been compared to older treatments. Additionally, few studies have assessed differences in the course of scleritis among different patient groups. We identify demographic factors, comorbidities and treatments associated with the resolution of acute scleritis.

METHODS

The records of patients with non-infectious anterior scleritis who presented between 1 January 2013 and 1 January 2018 were retrospectively reviewed.

RESULTS

A total of 141 patients (169 eyes) with anterior scleritis were identified. 92.9% had diffuse anterior scleritis, 5.0% had nodular anterior scleritis and 2.1% had necrotising scleritis. Topical corticosteroids were used in 66.7% of patients, systemic non-steroidal anti-inflammatory drugs (NSAIDs) in 48.9% and systemic corticosteroids in 37.6%. Non-corticosteroid immunomodulatory therapies were required in 37.6% of patients. In a Cox proportionate hazards model, factors positively associated with the resolution of an episode of scleritis included NSAID use (HR=2.145; 95% CI 1.200 to 3.832), Hispanic race (HR=2.991; 95% CI 1.115 to 7.341) and lupus erythematous (HR=6.175; 95% CI 1.774 to 21.489). Bilateral scleritis was negatively associated with resolution (HR=0.437; 95% CI 0.196 to 0.972). TNF-⍺ inhibitors (HR=3.346; 95% CI 1.277-8.763), NSAID use (HR=2.558; 95% CI 1.383 to 4.729), lupus erythematosus (HR=5.251; 95% CI 1.478 to 18.659) and Hispanic race (HR=3.198; 95% CI 1.022 to 10.005) were significantly positively associated with steroid sparing resolution.

CONCLUSION

Patient characteristics including a lupus diagnosis and Hispanic race were associated with faster times to symptom resolution and steroid sparing resolution, as were treatments including systemic NSAIDs and TNF-⍺ inhibitors. Due to limitations in the available data, this analysis did not account for disease severity. Future prospective studies will further elucidate the relationship between these factors and patient outcomes.

Rheumatoid Arthritis Associated Episcleritis and Scleritis: An Update on Treatment Perspectives

Episcleritis and scleritis are the most common ocular inflammatory manifestation of rheumatoid arthritis. Rheumatoid arthritis (RA) accounts for 8% to 15% of the cases of scleritis, and 2% of patients with RA will develop scleritis. These patients are more likely to present with diffuse or necrotizing forms of scleritis and have an increased risk of ocular complications and refractory scleral inflammation. In this review we provide an overview of diagnosis and management of rheumatoid arthritis-associated episcleritis and scleritis with a focus on recent treatment perspectives. Episcleritis is usually benign and treated with oral non-steroidal anti- inflammatory drugs (NSAIDs) and/or topical steroids. Treatment of scleritis will classically include oral NSAIDs and steroids but may require disease-modifying anti-rheumatic drugs (DMARDs). In refractory cases, treatment with anti TNF biologic agents (infliximab, and adalimumab) is now recommended. Evidence suggests that rituximab may be an effective option, and further studies are needed to investigate the potential role of gevokizumab, tocilizumab, abatacept, tofacitinib, or ACTH gel. A close cooperation is needed between the rheumatology or internal medicine specialist and the ophthalmologist, especially when scleritis may be the first indicator of an underlying rheumatoid vasculitis.

Intravitreal dexamethasone implant — a new treatment for idiopathic posterior scleritis: A case report

BACKGROUND

Posterior scleritis is one of the most easily missed and misdiagnosed diseases in ophthalmology. In this case we treated a patient with intravitreal dexamethasone implant that has not been extensively studied before.

CASE SUMMARY

A 40-year-old female patient who had anxiety, palpitation, and insomnia presented with eye pain and decreased vision in the left eye. An eye examination indicated that her visual acuity (VA) was 40/100. Her left eye presented conjunctival edema, mild exophthalmos, clear cornea, KP(-), and clear aqueous humor. In the fundus, there was a cinerous retinal protuberance. Ultrasonography showed “T-sign” and no systemic association was detected in laboratory examination. One month after injection of dexamethasone implant, the patient exhibited VA of 20/20, fundus serous retinal detachment disappeared, and intraocular pressure of both eyes was at the normal level.

CONCLUSION

Intravitreal injection of dexamethasone implant may be a safe and effective treatment for patients with idiopathic posterior scleritis.

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.

Eye pain in the white and quiet eye

PURPOSE OF REVIEW

Eye pain is one of the most common presenting symptoms in ophthalmology. It can range from bothersome to debilitating for patients, and it can be vexing for clinicians, especially in the white and quiet eye. The purpose of this review is to provide updates of recent literature regarding eye pain and to communicate our current understanding regarding the evaluation and management of conditions that cause eye pain with a relatively normal examination.

RECENT FINDINGS

This review concerns recent literature regarding eye pain in the white and quiet eye. It is arranged by cause of pain and discusses dry eye syndrome, recurrent corneal erosion, postrefractive surgical pain, eye strain, intermittent angle closure, benign essential blepharospasm, trochleodynia, trochleitis and trochlear headache, and posterior scleritis.

SUMMARY

Eye pain in the white and quiet eye remains a difficult-to-navigate topic for practitioners. However, a careful history and focused physical examination can elucidate the diagnosis in many cases. Recent updates to the literature have advanced our knowledge of how to identify and treat the underlying causes of eye pain.

Recognition, Diagnosis and Treatment of Chorioretinal Folds: Current Perspectives

Chorioretinal folds (CRFs) are undulations of the choroid and overlying Bruch’s membrane, retinal pigment epithelium and neurosensory retina. CRFs represent a clinical sign that is mandatory to investigate assuming their association with several ocular and extra-ocular disorders. Recent advances in retinal imaging have improved the characterization of CRFs. More importantly, retinal imaging may be useful to detect ocular complications secondary to chronic CRFs, including the development of choroidal neovascularization.

A rare case of bilateral sequential posterior scleritis in an elderly woman

A 63-year-old woman came with complaints of decreased vision and minimal pain on extraocular movements in the left eye and, after investigations, was diagnosed with posterior scleritis. Systemic steroid treatment helped resolve the symptoms and signs. One year later, she presented with right eye involvement. She was evaluated for systemic illness and, based on clinical and investigational findings, it was deduced that probably a sarcoidosis was predisposing her to the eye problem. She was provisionally diagnosed with bilateral sequential posterior scleritis secondary to sarcoidosis. She was prescribed oral steroids, which helped resolve her eye problem. She was next referred to a rheumatologist and a pulmonologist for further evaluation and treatment.

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.

An unusual case of Behcet disease with posterior scleritis: A case report

RATIONALE

Posterior scleritis is an ocular inflammatory disorder that can be associated with both infectious and non-infectious immune reactions. Behcet disease is a chronic, relapsing, multisystemic inflammatory disorder with uveitis. There are no reported cases of posterior scleritis with Bechet disease.

PATIENT CONCERNS

A 50-year-old man previously diagnosed with systemic Behcet disease presented with ocular pain and decreased vision in the left eye.

DIAGNOSIS

Posterior scleritis associated with Behcet disease was diagnosed based on optical coherence tomography showing choroidal folds, as well as contrast computed tomography and ultrasound sonography demonstrating thickening of the posterior sclera.

INTERVENTIONS

Treatment with systemic corticosteroids was initiated. Since inflammation relapsed during steroid tapering, anti-tumor necrosis factor-alpha (TNF-α) therapy was used in combination, and tapering of steroids was possible without recurrence of inflammation for 12 months.

OUTCOMES

Posterior scleritis was resolved and visual acuity improved. With the continuation of TNF-α therapy, oral prednisolone was successfully tapered and discontinued. No relapse of inflammation was observed at follow-up 1 year after discontinuation of prednisolone.

LESSONS

Ophthalmologists should be aware of the possibility of rare manifestation of posterior scleritis in patients with Behcet disease, and that combined use of systemic steroids and anti-TNF-α therapy may resolve the scleritis without recurrence of inflammation.

Point-of-Care Ultrasound in the Evaluation of the Acutely Painful Red Eye

BACKGROUND

Visual loss, ocular pain, and red eye are common presentations to front-line physicians in the emergency department, urgent care centers, or the primary care office. In recent decades, point-of-care ultrasound (POCUS) has been used by clinicians at the bedside in the evaluation and management of a vast array of patients, including those with ocular complaints.

CASE REPORT

A 33-year-old man presented to the emergency department with left eye pain for 4 weeks' duration. The physical examination revealed visual acuity of 20/400 in the affected eye and diffuse conjunctival injection with perilimbal sparing and scleral edema. Using POCUS, he was noted to have diffuse thickening of the globe wall in the symptomatic eye with a thin layer of fluid posterior to the globe in Tenon's space and mild enlargement of the optic nerve sheath diameter. He was ultimately diagnosed with posterior scleritis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Posterior scleritis carries the potential for significant visual impairment when the diagnosis is missed or delayed. POCUS findings can aid the front-line physician in making the diagnosis of posterior scleritis allowing earlier initiation of appropriate therapy and follow-up.

The clinical features of posterior scleritis with serous retinal detachment: a retrospective clinical analysis

AIM

To summarize the clinical features, systemic associations, risk factors and choroidal thickness (CT) changing in posterior scleritis (PS) with serous retinal detachment.

METHODS

This retrospective study included 23 patients diagnosed PS with retinal detachment from August 2012 to July 2017. All patients' medical history and clinical features were recorded. The examinations included best corrected visual acuity (BCVA), intraocular pressure (IOP), fundus examination, and routine eye examinations. Posterior coats thickness (PCT) was determined by B-scan ultrasound, the CT was measured by enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) and clinical data were compiled and analyzed.

RESULTS

After application of extensive exclusion criteria, 23 patients with PS remained (13 females, 10 males). The average age at presentation was 29.5±9.24 years old. Ocular pain and blurred vision were the two most common complained symptoms by patients. Anterior scleritis occurred in 12 patients, which was confirmed by ultrasound biomicroscopy (UBM) examination. Despite all patients displaying serous retinal detachment in their macula, no fluorescein leakage was observed in the macular area. Optic disc swelling was documented in 10 of the 23 eyes. From B-scan ultrasound examination, the PCT increased with fluid in Tenon's capsule demonstrated as a typical T-sign. The average PCT was 2.51±0.81 mm in the PS-affected eyes and only 1.09±0.29 mm in the unaffected eye (P<0.0001). The subfoveal CT was 442.61±55.61 µm, which correlated with axis length (r=-0.65, P=0.001) and PCT (r=0.783, P<0.001). The BCVA and IOP did not correlate with either CT or PCT.

CONCLUSION

PS with serous retinal detachment presented a variety of symptoms, such as pain, visual loss, and physical indicators. Typical T-sign detected by B-scan ultrasound is a useful confirmatory sign for PS diagnosis. Pathological increases in CT might be a potential predictive factor for inflammation.

Clinical Features, Treatment, and Visual Outcomes of Japanese Patients with Posterior Scleritis

Purpose: The purpose of this study is to describe clinical features and visual outcomes of Japanese patients with posterior scleritis.Methods: Clinical records of 10 patients (13 eyes) presenting between 2006 and 2016 were retrospectively reviewed.Results: The mean age was 50.1 ± 20.8 years; 50% were women, and three patients had bilateral disease. Associated anterior scleritis (11 eyes, 85%) and serous retinal detachment (8 eyes, 62%) were common at presentation. Treatment consisted of corticosteroids (all patients) and immunosuppressive agents (seven patients). The mean subfoveal choroidal thickness was significantly reduced over follow-up [611 μm at baseline, 298 μm (p < 0.01) at 1 month, and 238 μm (p < 0.01) at 1 year]. Recurrent inflammation was observed in six patients. A best-corrected visual acuity of 0.8 or better was achieved in all 13 eyes at 3 years and 71% of eyes at 5 years.Conclusion: Although 60% of patients with posterior scleritis had recurrence, visual outcomes were favorable.

Histopathological evaluation of scleritis

The sclera is an uncommon site of primary inflammation. Biopsy is infrequently employed in the evaluation of scleritis, but familiarity with its differential diagnosis is instrumental in ensuring efficient histological evaluation. This review provides a clinical overview of scleritis and describes the context in which scleral biopsy might arise. Most cases are associated with systemic autoimmune disease, but a sizeable proportion occur as an isolated disorder. Conditions mimicking autoimmune scleritis include infection and neoplasm. Histological patterns of inflammation in eyes removed surgically or at autopsy have been placed into three groups: (1) autoimmune scleritis characterised by varying mixtures of palisading granulomas, necrosis and vasculitis; (2) infectious scleritis, characterised by acute inflammation and necrosis; and (3) idiopathic scleritis, characterised by chronic non-specific inflammation with follicles and varying amounts of fibrosis. This traditional system of classification may be oversimplified. Aetiological or categorical classification is not always possible on small biopsies given the histopathological overlap of infectious and non-infectious scleritis.

Clinical profile of patients with posterior scleritis: A report from Eastern India

Purpose:

This study aimed to report the clinical profile of patients with posterior scleritis at a tertiary eye center in Eastern India.

Methods:

This was a single-center retrospective case series of patients who were diagnosed as posterior scleritis between January 2010 and December 2014, with a follow-up period of at least 6 months.

Results:

The study included 18 patients of posterior scleritis with a mean age of 41.2 ± 10.6 years (range: 26–63 years). With female preponderance (55.6%), majority of the posterior scleritis cases were unilateral (88.9%). Sixteen patients reported with diminution of vision, eleven patients (61.1%) had ocular pain on presentation, and five patients complained of headache. Concurrent anterior scleritis was found in three eyes (15%) with posterior scleritis. Choroidal folds and subretinal fluid at the posterior pole were the most common fundus findings and were seen in seven eyes (35%) each. No systemic association was detected in any patient even after extensive laboratory workup and multidisciplinary consultation. All patients received oral steroid, and 11 (61.1%) of them required intravenous pulse steroid therapy. Immunosuppressive was used in 6 (33.3%) patients, and oral azathioprine was the most common immunosuppressive used in the study. Recurrence was noted in eight eyes (40%). The mean best-corrected visual acuity improved to logarithm of the minimal angle of resolution (logMAR) 0.06 ± 0.051 at the final follow-up from 0.47 ± 0.45 logMAR at presentation (P = 0.00608).

Conclusion:

Posterior scleritis is relatively rare but can occur without systemic involvement. Aggressive immunomodulatory therapy is required to treat vision-threatening condition.

Atypical posterior scleritis mimicking choroidal melanoma

We report a case of atypical posterior scleritis mimicking amelanotic choroidal melanoma. A 30-year-old healthy Filipino man, with a history of painless subacute loss of vision in his left eye over 5 months, was referred to our institute for further workup and management. On examination, visual acuity of the left eye was 20/200. Anterior segment examination yielded unremarkable results, with injected conjunctiva and quiet episcleral blood vessels, while fundus examination revealed non-pigmented nasal choroidal mass, with significant subretinal fluid resembling amelanotic choroidal melanoma. Right eye examination yielded unremarkable results. The patient was diagnosed with atypical posterior scleritis, and treated with oral steroids for 2 weeks, with no improvement. A periocular steroid was then injected to the left eye, causing dramatic reduction in choroidal mass size, and complete resolution of subretinal fluid. The visual acuity improved to 20/28.5 one month after the injection. Timely treatment was crucial for minimizing vision-threatening complications.

[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.

Posterior Scleritis with Choroidal Effusion Secondary to Herpes Zoster Ophthalmicus

PURPOSE

To describe a case of posterior scleritis with serous choroidal detachment that occurred as an acute complication of herpes zoster ophthalmicus (HZO).

METHODS

Retrospective case report.

RESULTS

A 75-year-old female presented with 3 days of painful, decreased vision in her left eye 1 week after being diagnosed with HZO. She had unilateral crusted vesicular lesions in the V1 dermatomal distribution and corneal pseudodendrites. Funduscopic examination demonstrated a large choroidal detachment in her left eye. B-scan ultrasonography revealed unilaterally thickened sclera consistent with posterior scleritis. She was treated with oral prednisone and a 2-week course of intravenous acyclovir. Two weeks after the initiation of treatment, her vision had improved and she demonstrated complete resolution of her pseudodendrites, posterior scleritis, and choroidal detachment.

CONCLUSIONS

Prompt recognition and treatment of this unique combination of clinical manifestations of HZO resulted in significant improvement in vision and resolution of the scleritis and choroidal detachment.

Neuroimaging in the Diagnostic Evaluation of Eye Pain

Ocular or eye pain is a frequent complaint encountered not only by eye care providers but neurologists. Isolated eye pain is non-specific and non-localizing; therefore, it poses significant differential diagnostic problems. A wide range of neurologic and ophthalmic disorders may cause pain in, around, or behind the eye. These include ocular and orbital diseases and primary and secondary headaches. In patients presenting with an isolated and chronic eye pain, neuroimaging is usually normal. However, at the beginning of a disease process or in low-grade disease, the eye may appear "quiet," misleading a provider lacking familiarity with underlying disorders and high index of clinical suspicion. Delayed diagnosis of some neuro-ophthalmic causes of eye pain could result in significant neurologic and ophthalmic morbidity, conceivably even mortality. This article reviews some recent advances in imaging of the eye, the orbit, and the brain, as well as research in which neuroimaging has advanced the discovery of the underlying pathophysiology and the complex differential diagnosis of eye pain.

Uveitis Specialists and Rheumatologists Select Different Therapies for Idiopathic Non-necrotizing Anterior Scleritis

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.