Orbital/ocular inflammatory involvement in VEXAS syndrome: Data from the international AIDA network VEXAS registry

VEXAS syndrome is a recently described monogenic autoinflammatory disease capable of manifesting itself with a wide array of organs and tissues involvement. Orbital/ocular inflammatory manifestations are frequently described in VEXAS patients. The objective of this study is to further describe orbital/ocular conditions in VEXAS syndrome while investigating potential associations with other disease manifestations. In the present study, twenty-seven out of 59 (45.8 %) VEXAS patients showed an inflammatory orbital/ocular involvement during their clinical history. The most frequent orbital/ocular affections were represented by periorbital edema in 8 (13.6 %) cases, episcleritis in 5 (8.5 %) patients, scleritis in 5 (8.5 %) cases, uveitis in 4 (6.8 %) cases, conjunctivitis in 4 (6.8 %) cases, blepharitis in 3 (5.1 %) cases, orbital myositis in 2 (3.4 %) cases. A diagnosis of systemic immune-mediated disease was observed in 15 (55.6 %) cases, with relapsing polychondritis diagnosed in 12 patients. A significant association was observed between relapsing polychondritis and orbital/ocular involvement in VEXAS syndrome (Relative Risk: 2.37, 95 % C.I. 1.03-5.46, p = 0.048). Six deaths were observed in the whole cohort of patients after a median disease duration of 1.2 (IQR=5.35) years, 5 (83.3 %) of which showed orbital/ocular inflammatory involvement. In conclusion, this study confirms that orbital/ocular inflammatory involvement is a common finding in VEXAS patients, especially when relapsing polychondritis is diagnosed. This makes ophthalmologists a key figure in the diagnostic process of VEXAS syndrome. The high frequency of deaths observed in this study seems to suggest that patients with orbital/ocular involvement may require increased attention and more careful follow-up.

Mimickers of anterior uveitis, scleritis and misdiagnoses- tips and tricks for the cornea specialist

BACKGROUND

Anterior uveitis, inflammation of the anterior chamber and related structures, is a cohort of diseases that can present to almost any general or sub-specialty Ophthalmology practice. Its features classically involve anterior chamber cell and flare. Below the surface of these two signs exist a panoply of diagnoses. BODY: The purpose of this review is to provide a general framework for diagnoses of anterior uveitis that are often missed as well as non-uveitic pathologies that often mimic anterior uveitis. Diagnostic deviation in either direction can have vision-threatening and rarely life-threatening consequences for patients. Using a comprehensive literature review we have collected a broad spectrum of etiologies of anterior uveitis that are easily missed and non-uveitic pathologies that can masquerade as anterior uveitis.

CONCLUSIONS

We present a focused review on specific misdiagnosed anterior uveitis pathologies and some of the conditions that can masquerade as anterior uveitis and scleritis.

The enigma of sclera-specific autoimmunity in scleritis

Scleritis is a severe and painful ophthalmic disorder, in which a pathogenic role for collagen-directed autoimmunity was repeatedly suggested. We evaluated the presence of sclera-specific antibodies in a large cohort of patients with non-infectious scleritis. Therefore, we prospectively collected serum samples from 121 patients with non-infectious scleritis in a multicenter cohort study in the Netherlands. In addition, healthy (n = 39) and uveitis controls (n = 48) were included. Serum samples were tested for anti-native human type II collagen antibodies using a validated enzyme-linked immunosorbent assay (ELISA). Further, sclera-specific antibodies were determined using indirect immunofluorescence (IIF) on primate retinal/scleral cryosections. Lastly, human leukocyte antigen (HLA) typing was performed in 111 patients with scleritis. Anti-type II collagen antibodies were found in 13% of scleritis patients, in 10% of healthy controls and in 11% of uveitis controls (p = 0.91). A specific reaction to scleral nerve tissue on IIF was observed in 33% of patients with scleritis, which was higher than in healthy controls (11%; p = 0.01), but similar to uveitis controls (25%; p = 0.36). Reactivity to the scleral nerve tissue was significantly associated with earlier onset of scleritis (48 versus 56 years; p < 0.001), bilateral involvement (65% versus 42%; p = 0.01), and less frequent development of scleral necrosis (5% versus 22%; p = 0.02). HLA-B27 was found to be twice as prevalent in patients with scleritis (15.3%) compared to a healthy population (7.2%). In conclusion, scleral nerve autoantibody reactivity was more common in scleritis and uveitis patients in contrast to healthy controls. Further research is needed to characterize these scleral-nerve directed antibodies and assess their clinical value.

Intravenous cyclophosphamide therapy for patients with severe ocular inflammatory diseases who failed other immunomodulatory therapies

BACKGROUND

Ocular inflammatory diseases, including scleritis and uveitis, have been widely treated with immunomodulatory therapies (IMTs) as a steroid-sparing approach. Such strategy includes conventional therapies (antimetabolites, alkylating agents, and calcineurin inhibitors) as well as biologic agents like adalimumab, infliximab, rituximab, and tocilizumab. Cyclophosphamide (CP) is an alkylating agent and mainly inhibits the functioning of both T and B cells. Though known to have potential adverse events, including bone marrow suppression, hemorrhagic cystitis, and sterility, CP has been shown to be efficacious, especially in recalcitrant cases and when used intravenous (IV) for a limited period.

MAIN FINDINGS

We conducted a retrospective case-series to assess the safety and efficacy of CP therapy for patients with severe ocular inflammatory diseases who failed other IMTs. Medical records of 1295 patients who presented to the Uveitis Clinic at the Byers Eye Institute at Stanford between 2017 and 2022 were reviewed. Seven patients (10 eyes) who received CP therapy for ocular inflammatory diseases with at least one year of follow-up were included. The mean age of the patients (4 males, 3 females) was 61.6 ± 14.9 (43.0-89.0) years. Clinical diagnoses included necrotizing scleritis (5 eyes), peripheral ulcerative keratitis (2 eyes), orbital pseudotumor (1 eye), HLA-B27 associated panuveitis and retinal vasculitis (2 eyes). Ocular disease was idiopathic in 3 patients, and was associated with rheumatoid arthritis, IgG-4 sclerosing disease, dermatomyositis, and ankylosing spondylitis in 1 patient each. All the patients had history of previous IMT use including methotrexate (5), mycophenolate mofetil (3), azathioprine (1), tacrolimus (1), adalimumab (2), infliximab (4), and rituximab (1). The mean follow-up time was 34.4 ± 11.0 (13-45) months, and mean duration of CP therapy was 11.9 ± 8.8 (5-28) months. Remission was achieved in 5 patients (71.4%). Four patients (57.1%) experienced transient leukopenia (white blood cell count < 4000/mL).

SHORT CONCLUSION

CP therapy can be considered a potentially effective and relatively safe therapeutic option for patients with severe ocular inflammatory diseases who failed other IMTs including biologics (TNFa and CD20 inhibitors).

Scleritis following intravitreal brolucizumab injection: a case series

BACKGROUND

This study reports the first cases of scleritis following intravitreal brolucizumab (IVBr) injection for nAMD, emphasizing the need to be aware of the possibility of scleritis following IVBr injections.

CASE PRESENTATION

Case 1. A 74-year-old Japanese man with nAMD complained of conjunctivitis and decreased vision in the right eye 8 days after his eighth IVBr injection. Examination revealed scleritis without anterior inflammation. Topical 0.1% betamethasone and 0.3% gatifloxacin eye drops were started. The scleritis worsened in the following 2 weeks and became painful. He underwent sub-Tenon's capsule triamcinolone acetonide (STTA) injection. Two days later, he returned with a complaint of severe vision loss. Fundus examination revealed retinal artery occlusion, vasculitis, and vitreous opacity in the right eye. Vitreous surgery was performed.

CASE 2

An 85-year-old Japanese woman with nAMD in the right eye complained of reddening of the eye 27 days after her fifth IVBr injection. Examination showed conjunctivitis and scleritis without anterior inflammation in the right eye. She was started on 0.1% fluorometholone and 0.5% levofloxacin hydrate eye drops. The scleritis worsened in the following 3 weeks. Her treatment was switched to 0.1% betamethasone eye drops. One month later, the scleritis had improved and a sixth IVBr injection was administered. There was no worsening of the scleritis at that time. However, 1 month after a seventh IVBr injection, she complained of severe hyperemia and decreased vision. Fundus examination revealed vitreous opacification. She underwent STTA, and the vitreous opacity improved in 24 days. Case 3. A 57-year-old Japanese man with nAMD complained of pain and decreased vision in the right eye 21 days after a fourth IVBr injection. Examination revealed scleritis with high intraocular pressure but no anterior chamber or fundus inflammation. STTA and topical eye drops were performed. One month later, scleritis improved but visual acuity didn't due to progression of nAMD.

CONCLUSIONS

Intraocular inflammation following IVBr injection may progress to the posterior segment. Scleritis can occur after IVBr injection, and topical eye drops alone may not be sufficient for initial treatment. Clinicians should consider the possibility of scleritis in patients with worsening inflammation after IVBr injection.

Association between advanced glycation end products and uveitis/scleritis activity in patients with active immune-mediated ocular inflammatory diseases

PURPOSE

To investigate for association between skin autofluorescence (SAF) advanced glycation end products (AGEs) and uveitis/scleritis activity in systemic inflammatory disease-related active non-infectious uveitis/scleritis patients.

METHODS

This cross-sectional study was conducted at Siriraj Hospital during October 2019 to March 2020. AGEs were measured by SAF method in systemic immune-related disease patients with active uveitis/scleritis, and those results were compared with those of healthy age-matched controls.

RESULTS

Thirty-one active non-infectious uveitis/scleritis patients and 31 age-matched controls were enrolled. The mean age of patients was 40.0 ± 12.8 years, and most were female (55.0%). The most common associated systemic immune-related disease was Vogt-Koyanagi-Harada disease (n = 14). Mean SAF AGE level in the study group compared to the control group was 2.38 ± 0.66 arbitrary units (AU) versus 2.58 ± 0.56 AU, respectively (p = 0.20). Multivariate analysis showed decreased SAF AGE level to be significantly associated with active ocular inflammation, (odds ratio: 0.01, 95% confidence interval: 0.00004-0.81; p = 0.04).

CONCLUSIONS

SAF AGE level was not so far found to be a reliable biomarker for indicating uveitis/scleritis activity in systemic immune-related disease patients with active ocular inflammation.

CLINICAL TRIAL REGISTRATION

Thai Clinical Trials Registry, https://www.thaiclinicaltrials.org/ . (Reg. No. TCTR20200114004, registered date 01/01/2020, beginning date of the trial 10/01/2019).

Ocular manifestations of granulomatosis with polyangiitis: report from a tertiary eye care center

PURPOSE

To report demographic characteristics and ophthalmological manifestations of patients with granulomatosis with polyangiitis (GPA) in a tertiary eye care center in Turkey.

METHODS

Medical records of patients with GPA-related ocular manifestations evaluated between 2013 and 2023 were included. Demographic and clinical characteristics of the patients including nature of systemic involvement, ophthalmologic symptoms and signs, laboratory investigations and treatment modality were reviewed.

RESULTS

Twelve eyes of 10 patients (5 female/5 male) were included. The mean age was 57.2 ± 12.2 (35-71) years. Five (50%) patients were already diagnosed with GPA. Ocular involvement was the first manifestation of GPA in 3 patients. The remaining 2 patients had simultaneous systemic and ocular symptoms at presentation. Conjunctival hyperemia (9 eyes) and pain (7 eyes) were the most frequent presenting symptoms followed by blurred vision (3 eyes). The frequencies of ocular manifestations were as follows:episcleritis (3 eyes), isolated peripheral ulcerative keratitis (PUK) (3 eyes), scleritis (3 eyes), simultaneous PUK and scleritis (2 eyes) and periorbital mass (1 eye).

CONCLUSION

Ophthalmological manifestations can be the initial findings in GPA. Since GPA can affect different structures of the eye, it sometimes might be challenging for ophthalmologists. Therefore, it is crucial for ophthalmologists to be well-informed about GPA-related ocular findings and to have a high index of suspicion for GPA. Although PUK associated with scleritis is highly suggestive for GPA, isolated cases of PUK or scleritis can be seen in GPA. Therefore, it is important to adopt a multidisciplinary approach, consider GPA in differential diagnosis, and benefit from accurate diagnostic tests.

Potential Biomarkers for Noninfectious Scleritis Identified by Serum and Tear Fluid Proteomics

Purpose

Scleritis is an extremely painful and potentially blinding inflammation of the sclera with unknown pathogenesis and unpredictable course. To gain insight in its disease process and identify biomarker candidates, we performed extensive proteomics in serum and tear fluid.

Design

Prospective multicenter cohort study.

Participants

A total of 121 patients with noninfectious scleritis (of which 39 active cases), 30 healthy controls, and 23 disease controls (uveitis and rheumatoid arthritis) were enrolled in the Netherlands from 2020 to 2022.

Methods

Serum, tear fluid of both eyes, and clinical data were gathered. The level of 368 inflammatory proteins was measured using proximity extension assays. Results were validated in an independent cohort of 15 patients with scleritis, and using addressable laser bead immunoassay, or enzyme-linked immunoassays. In addition, we studied an extended panel of matrix metalloproteinases in tear fluid of necrotizing scleritis with addressable laser bead immunoassay.

Main Outcome Measures

Statistically significant differences in the level of inflammatory proteins between patients with scleritis and control groups.

Results

Proteomics revealed 18 significantly upregulated or downregulated serum proteins in active scleritis cases compared with all control groups in both the discovery cohort and the validation cohort. The most upregulated protein was nuclear migration protein nudC (NudC; P = 0.0032), a protein involved in neurogenesis. The other significant hits included proteins involved in T-cell activation, apoptosis, epithelial barrier maintenance, and angiogenesis. Our tear fluid analysis showed matrix metalloproteinase 9 (MMP9) to be upregulated in the tear fluid of patients with scleral necrosis.

Conclusions

The results of our proteomics analysis suggest a role for neurogenesis, T-cell activation, disruption of epithelial barrier, and angiogenesis in the pathogenesis of scleritis, and highlight MMP9 and NudC as biomarkers with potential clinical relevance.

Funding Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

[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.

Ocular manifestations following COVID-19 vaccination

BACKGROUND

Immunologic and inflammatory adverse effects following vaccination against COVID-19 are being reported. While some reactions may develop denovo others concern its immunogenic effect in patients with pre-existing inflammatory conditions.

METHODS

Retrospective consecutive patients diagnosed with ocular inflammatory manifestations within 8 weeks of receiving COVID-19 vaccination who presented to a tertiary eye care centre in South India.

RESULTS

Ninety-eight eyes of 67 patients presenting with ocular inflammatory manifestations within 8 weeks following COVID-19 vaccination were studied. The mean age was 43 years (+/- 14.82; range 19-80 years). The most common presentations were anterior uveitis (n = 31, 31.7%), followed by panuveitis (n = 24, 24.5%). The mean time to onset of symptoms was 25 days (+/- 15.48; range 2-55 days) following a dose of vaccine. Among all patients, 39 (58.2%) had a previous history of ocular inflammation. Mean presenting visual acuity was 0.4 (0-4) logMAR units and mean final visual acuity was 0.2 (0-4) logMAR units. The causes for reduced vision included of cystoid macular edema (n=2, 2%), chorioretinal atrophy (n=2.2%), optic atrophy (n=1.1%), retinal vascular occlusion (n=1.1%) and acute retinal necrosis (n=1.1%).

CONCLUSION

Infective and immunogenic adverse events should be watched out for after COVID-19 vaccination. It is difficult to establish causality for such manifestations, nevertheless, most of them were mild and had good final visual outcomes.

Autoimmune Inflammatory Eye Disease: Demystifying Clinical Presentations for the Internist

PURPOSE OF REVIEW

Provide a framework for recognizing key symptoms and clinical findings in patients with autoimmune inflammatory eye disease.

RECENT FINDINGS

The most common manifestations of autoimmune inflammatory eye disease are episcleritis, scleritis, uveitis (anterior, intermediate, posterior, and panuveitis), and keratoconjunctivitis sicca. Etiologies can be idiopathic or in association with a systemic autoimmune condition. Referral of patients who may have scleritis is critical for patients presenting with red eyes. Referral of patients who may have uveitis is critical for patients presenting often with floaters and vision complaints. Attention should also be directed to aspects of the history that might suggest a diagnosis of a systemic autoimmune condition, immunosuppression, drug-induced uveitis, or the possibility of a masquerade condition. Infectious etiologies should be ruled out in all cases. Patients with autoimmune inflammatory eye disease may present with ocular or systemic symptoms alone, or in combination. Collaboration with ophthalmologists and other relevant specialists is vital to optimal long-term medical care.

The ocular manifestations of relapsing polychondritis

PURPOSE

Relapsing polychondritis (RPC) is a rare, multi-system, inflammatory disorder. Ocular disease is estimated to occur in 14-67% of patients with RPC, and any ocular structure can be affected. Published case reports and series of RPC were analysed to determine the frequency and nature of the ocular manifestations of RPC, including the age and gender distribution.

METHODS

A literature search of the MEDLINE database for case reports and series on RPC was conducted in October 2021 using search terms [relapsing polychondritis (MeSH Major Topic)] OR [relapsing polychondritis (Title/Abstract)]. Articles were included if the diagnosis of RPC was confirmed using established diagnostic criteria and if the paper described the clinical features of patients with RPC.

RESULTS

546 articles (454 case reports and 92 case series) described the clinical features in a total of 2414 patients with RPC. 49% of patients with RPC had ocular involvement, and this was a presenting feature in 21%. The most common ocular manifestations were scleritis (32%), episcleritis (31%) and uveitis (23%).

CONCLUSION

Many patients with RPC will be seen by an ophthalmologist during the course of their disease. Knowledge and awareness of RPC and its ocular manifestations is therefore essential to enable the ophthalmologist to make the diagnosis.

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.

IgG4-related ophthalmic disease masquerading as ciliary body tumors and scleritis in both eyes: a case report

BACKGROUND

To report a rare case of IgG4-related ophthalmic disease (IgG4-ROD) manifesting as intraocular masses and scleritis in both eyes in a 61-year-old male and to investigate the changes in multimodal imaging features of the lesion sites and helper T-cell type 1 (Th 1)/Th 2/Th 17 cytokine levels in the aqueous humor.

CASE PRESENTATION

A patient with IgG4-ROD seemingly manifested with an intraocular tumor in the left eye and sequentially, with an inflammatory mass in the ciliary body and scleritis in the right eye. The patient complained of vision loss of 6 months duration in the left eye at his first visit. With a preliminary diagnosis of an intraocular tumor, enucleation of the left eyeball and histopathological examination were performed. Approximately 3 months later, the patient started to experience headache, eye pain, and declining vision in the right eye. Ophthalmic imaging revealed a ciliary mass and scleritis. Th 1/Th 2/Th 17 cytokine levels and multimodal imaging findings were analyzed before and after corticosteroid treatment. Histopathological examination and immunohistochemistry (IHC) of the enucleated left eye demonstrated lymphoplasmacytic infiltration with an IgG4+/IgG+ cell ratio of approximately 40%, pointing to the diagnosis of probable IgG4-ROD. Long-term treatment with corticosteroids led to significant improvement in the signs and symptoms of the left eye. Th 1/Th 2/Th 17 cytokine profile monitoring of the aqueous humor and multimodal imaging of the right eye showed gradual regression of the mass and attenuation of ocular inflammation during treatment.

CONCLUSIONS

Patients with an atypical presentation of IgG4-ROD, such as intraocular masses and scleritis, are likely to experience a significant delay in diagnosis. This case demonstrates the significance of IgG4-ROD in the differential diagnosis of intraocular tumors and ocular inflammation. IgG4-RD is a newly diagnosed disease with multi-organ involvement and little is known about its pathogenesis, particularly in the eye. The present case will open new challenges in the clinico-pathological diagnosis and research of this disease. Combined investigations of multimodal imaging and cytokine level detection of intraocular fluid provide a new and effective way to monitor disease progression.

Ocular manifestations in IgA nephropathy

Immunoglobulin A nephropathy (IgAN) is a rare but important systemic disease with or without ocular manifestations. We describe 4 cases of IgAN presenting with scleritis and review the various ocular manifestations in patients with IgAN. We found 55 cases with ocular manifestations in patients with prior or newly-diagnosed IgAN described in 38 publications. The most common ocular manifestations of IgAN were episcleritis (23.6%), scleritis (16.4%), hypertensive retinopathy or retinal vasculopathy (20.0%), and uveitis (14.5%). The median age at presentation was 36.5 years, with 54.5% female patients. 61.8% had history of IgAN prior to ocular involvement, while 29.1% had ocular presentations as the first manifestation of IgAN. The majority received systemic corticosteroids and/or immunosuppressants. Additionally, we report 4 women with anterior scleritis and previous diagnosis of IgAN. All 4 were treated with topical and systemic corticosteroids. Three out of 4 patients had no recurrence for at least 1 year since the first presentation. IgAN is a rare but important systemic association to be considered in ocular inflammatory conditions. Timely recognition and comanagement of the disease with nephrologist could reduce disease morbidity.

Ocular Adverse Events after Coronavirus Disease 2019 mRNA Vaccination: Matched Cohort and Self-Controlled Case Series Studies Using a Large Database

PURPOSE

To investigate the risk of ocular adverse events after Coronavirus Disease 2019 (COVID-19) mRNA vaccination.

DESIGN

Matched cohort and self-controlled case series (SCCS) studies.

PARTICIPANTS

We used a population-based database of medical claims and vaccination records in a large Japanese city. In the matched cohort study, we identified individuals who received COVID-19 vaccination (BNT162b2) from February 2021 to September 2021. One control was selected from nonvaccinated individuals by matching time, date of birth, sex, Charlson comorbidity index, and the enrollment period for health insurance. In the SCCS study, we analyzed individuals who developed ocular adverse events.

METHODS

In the matched cohort study, we applied the Kaplan-Meier estimator to estimate the cumulative incidence of ocular adverse events over 21 days after the first dose and 84 days after the second dose. In the SCCS method, we used conditional Poisson regression to estimate the incidence rate ratio (IRR) of ocular adverse events during the risk periods (0-21 days after the first dose and 0-84 days after the second dose) compared with the remaining periods.

MAIN OUTCOME MEASURES

Composite outcome of uveitis, scleritis, retinal vein occlusion (RVO), and optic neuritis.

RESULTS

There were 99 718 pairs eligible for the matched cohort study after the first dose (mean age, 69.3 years; male, 44%). The vaccinated and control groups developed 29 and 21 events, respectively, over 21 days after the first dose, and 79 and 28 events, respectively, over 84 days after the second dose. The differences in cumulative incidence (reference, the control group) were 2.9 (95% confidence interval, -14.5 to 19.1) events/100 000 persons and 51.3 (16.2-84.3) events/100 000 persons, respectively, for the first and second doses. The SCCS study showed the IRRs of 0.89 (0.62-1.28) and 0.89 (0.71-1.11) for the first and second doses, respectively.

CONCLUSIONS

The matched cohort analysis found an increased risk for the composite outcome after the second dose; however, the SCCS analysis showed no increased risk. Considering that the SCCS can cancel out time-invariant confounders, the current results suggest that COVID-19 vaccination is unlikely to causally increase the risk of ocular adverse events.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

NECROTIZING SCLERITIS AND RHEUMATOID ARTHRITIS: A CLINICAL CASE REPORT SUPPORTED BY A BRIEF REVIEW WITH RISK OF BIAS ANALYSIS

INTRODUCTION

Necrotizing scleritis (NS) presents 30%-40% as having a systemic autoimmune condition.

OBJECTIVE

To present a clinical case report and a systematic review of necrotizing scleritis with ocular manifestation as the first sign of rheumatologic disease.

METHODS

The present study was elaborated according to the rules of CARE.

CASE REPORT

A female patient, 63 years old, a white, administrative assistant, presented irritation, low visual acuity (LVA) in the left eye (LE), and headache. Biomicroscopy (BIO) in the right eye (RE) was normal, and the LE showed hyperemia and scleral thinning. After 1 month, the patient returns without signs of infectious diseases in the exams, and after a rheumatological evaluation with a diagnosis of rheumatoid arthritis, methotrexate and prednisone are prescribed. After 2 months, she relapsed and started treatment with anti-TNF, with remission after the 4th dose. After 1 year, she evolved with LVA in LE.

RESULTS

A total of 244 articles were found, 104 articles were evaluated and 10 were included in the brief review. The symmetrical Funnel Plot does not suggest a risk of bias.

CONCLUSION

Both in the present case report and the literary findings, it was evidenced that the ophthalmologic findings may precede the systemic changes of the disease for the early diagnosis of rheumatoid arthritis.

Serous Choroidal Detachment and Scleritis Associated with Necrotic Choroidal Tumors

Purpose

The aim of the study was to describe choroidal detachments and concurrent scleritis associated with necrotic choroidal metastasis or melanoma.

Methods

We conducted a retrospective case series.

Results

We report 4 patients with scleritis and choroidal detachment with an underlying malignant choroidal tumor. All patients underwent fine-needle aspiration biopsy for cytopathologic characterization of their choroidal tumor, and they all demonstrated evidence of tumor necrosis. Two patients were diagnosed with choroidal metastasis from lung and esophageal adenocarcinoma. Both patients ultimately expired from systemic metastasis. The remaining 2 patients were diagnosed with choroidal melanoma and were successfully treated with plaque radiotherapy.

Conclusion

Choroidal detachment with concurrent scleritis can occur as a rare sequelae of tumor necrosis of an underlying choroidal malignancy.

The eye is a common site of granulomatosis with polyangiitis. A collaborative study

BACKGROUND

Ocular manifestations of granulomatosis with polyangiitis (GPA) have been reported in a limited number of studies and with largely variable frequency. Here we report on the clinical, diagnostic, and therapeutic features of a cohort of 63 GPA patients, with particular regard to 22 of them with ophthalmic involvement (35%).

METHODS

Clinical manifestations, results of immunological findings, histopathological pictures, imaging data, Birmingham Vasculitis Activity Score, therapeutic regimens, and outcomes were retrospectively analyzed. At diagnosis, in addition to a structured clinical assessment, all patients underwent a comprehensive ophthalmologic examination.

RESULTS

The most frequently involved organs were kidneys, lungs, ear/nose/throat, and eyes. Ocular manifestations were bilateral in 32%. The three most commonly diagnosed ophthalmologic manifestations were scleritis (36%), retro-orbital pseudotumor or orbital mass (23%), and episcleritis (13%). Ocular and systemic involvement were simultaneously present at onset in 41% of the patients; systemic involvement was followed by ocular lesions in 36%; ocular inflammation was followed by systemic manifestations in 18%; and an orbital mass in the absence of systemic disease characterized 5%. Glucocorticoids plus cyclophosphamide and glucocorticoids plus rituximab were the combined therapies most frequently employed during remission induction and remission maintenance, respectively. Persistent ophthalmologic and extra-ocular remissions were achieved in 77 and 64% of the patients, respectively. One to three systemic relapses were diagnosed in 7 patients (31.8%). At the last follow-up, a visual outcome 20/40 or better in 31 (70%) of 44 eyes was determined.

CONCLUSIONS

The eye was involved in over one third of our patients with GPA. Increased awareness, early diagnosis, and multi-specialty collaboration are critical in achieving a favorable outcome of GPA.

Nocardia arthritidis scleritis: A case report

Purpose

This report describes a case and management of a 69-year-old female with infectious scleritis found to be caused by Nocardia arthritidis species.

Observations

Our patient presented with severe constant pain in the left eye (OS) following cataract surgery. She had a pertinent past medical history significant for renal transplantation (on oral tacrolimus, mycophenolate, and prednisone). Slit lamp examination OS (1 month after cataract surgery) demonstrated 3+ injection temporally accompanied by scleral thickening and multiloculated abscesses with purulent drainage from small conjunctival erosions. The abscesses were debrided and sent for gram stain and culture. The patient was treated with repeated subconjunctival injections of antibiotics and an antifungal; topical amphotericin, vancomycin, and amikacin; and oral trimethoprim-sulfamethoxazole (double strength). Two separate gram stains with cultures confirmed the diagnosis and species identification. The patient responded well to repeat subconjunctival injections early on in addition to the prescribed regimen, remaining free of disease at the last follow-up (12 months following presentation).

Conclusions and Importance

This unique case demonstrates infectious scleritis caused by an uncommon Nocardia species (N. arthritidis) that was successfully treated with similar strategies used for other reported Nocardia species. As Nocardia scleritis can lead to adverse outcomes if not treated promptly and properly, it should be considered on the differential diagnoses in an immunocompromised patient who presents with acute ocular symptoms after any recent ocular surgery.

Necrotizing Scleritis as a Manifestation of Eosinophilic Granulomatosis With Polyangiitis: A Case Report

Eosinophilic granulomatosis with polyangiitis (EGPA) is an ANCA-associated vasculitis characterized by the development of necrotizing granulomas rich in eosinophils and vasculitis of small and medium vessels, with compromise of the respiratory tract, peripheral nervous system, and least frequent ocular involvement. We report the case of a 54-year-old Caucasian man with a history of EGPA who presented ocular pain, red eye, vision loss, and evidence of scleral slimming compatible with necrotizing scleritis. The patient was treated with systemic steroids and cyclophosphamide, which reduced the ocular pain but did not improve visual acuity, needing surgical treatment of the scleral coverage defect. While necrotizing scleritis is an unusual manifestation of EGPA, it should be part of the differential diagnosis in patients with red eye or ocular pain as an accurate diagnosis and prompt treatment could reduce local complications.

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.

The Atypical Red Eye: A Case of Scleritis with Peripheral Ulcerative Keratitis Secondary to Granulomatosis with Polyangiitis

This report presents a rare case of scleritis with peripheral ulcerative keratitis secondary to granulomatosis with polyangiitis (GPA). A 65-year-old Caucasian male presented to a regional ophthalmology service with an atypical red eye. His immune work-up demonstrated positive anti-neutrophil cytoplasmic IgG autoantibodies (ANCA) with anti-proteinase 3 antibody (PR3) elevation. Multi-system vasculitis was discovered including lung, liver, bladder, prostate, nasal and paranasal sinuses involvement. His ocular sequelae included significant peripheral corneal thinning requiring cyanoacrylate gluing, juxtalimbal conjunctival resection, and bandage lens placement. He was treated with systemic methylprednisolone and rituximab achieving remission with ongoing prednisone and methotrexate maintenance therapy. This case demonstrates the importance of recognizing ocular manifestations of GPA as a first presentation of systemic vasculitis.

Use of optical coherence tomography angiography in the uveitis clinic

As optical coherence tomography angiography is revolutionizing the ophthalmology world, the uveitis community is learning to understand where and how this new powerful imaging tool fits into the management of the panorama of ocular inflammations and infections. A non-invasive method of studying the retinal and choroidal vasculature, OCTA allows for the assessment of vessel density changes during active and inactive uveitis making it the natural imaging application of choice in uveitis clinical trials. However, these data and results are of limited utility to the ophthalmologists who are looking to apply OCTA in their everyday uveitis clinic. If employed strategically, OCTA can be a powerful tool for the uveitis specialist to evaluate iris involvement in viral uveitis; to assess the integrity of the vascular layers in the settings of white dot syndromes; to distinguish inflammatory choroidal neovascularization from outer retinal avascular inflammatory material; and to diagnose and follow infectious choroidal granulomas and satellite foci of chorioretinal inflammation without the need to administer dyes. The present review will analyze all the recent publications that apply OCTA in uveitis to offer the reader a guide on how to maximize the utility of this imaging modality in a clinical practice.

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.

Posterior ocular manifestations following BNT162b2 mRNA COVID-19 vaccine: a case series

Purpose

To report the occurrence of posterior ocular adverse events following the administration of the BNT162b2 mRNA vaccine against SARS-CoV-2.

Methods

A retrospective consecutive case series, in which the medical files of patients presenting with ocular adverse events within 30 days of the vaccine inoculation, were analyzed.

Results

Four patients (2 females) were included in the study. The diagnoses included: posterior scleritis, paracentral acute middle maculopathy, herpes panuveitis, and Vogt–Koyanagi–Harada (VKH)-like uveitis. Three of the patients had no relevant ocular history, but the patient who developed scleritis was in remission without medical therapy for four years, until the flare-up, which occurred one day after the vaccine. All patients improved with treatment.

Conclusion

Though a causal relationship cannot be definitively established, the temporal relationship suggests a possible link between the COVID-19 vaccine and the posterior ocular complications. The benefits of vaccination clearly outweigh the potential adverse effects; however, ophthalmologists should be aware of the potential for vaccine-associated uveitis.

Patterns of Non-Infectious Scleritis across a Tertiary Eye Care Network Using the Indigenously Developed Electronic Medical Record System-eyeSmart

PURPOSE

To report the pattern of noninfectious scleritis across a tertiary eye-care network.

METHODS

A three-year retrospective review of patients diagnosed with noninfectious scleritis was performed. Data were retrieved using diagnostic terms assigned to scleritis through the in-house eyeSmart-electronic medical record system.

RESULTS

1103 patients, with a mean age of 44.33 ± 14.38 years and a median follow-up of 199.5 days (range 32-685) were enrolled. Unilateral disease was noted in 85%. Diffuse anterior scleritis (n = 542, 42.51%) and nodular scleritis (n = 482, 38.12%) were the commonest subtypes. Systemic immune disease association was present in 65 (5.89%). Treatment at onset was topical corticosteroids (n = 372, 36.54%) followed by oral non-steroidal anti-inflammatory drugs (n = 351, 34.45%), oral corticosteroids in 184 (19.04%), and immunomodulators in 32 patients (3.54%).

CONCLUSIONS

This study depicts the pattern of various noninfectious scleritis in a large cohort of patients. The present study helped to further customize the electronic medical records to minimize several data capture limitations.

Clinical Relevance of Autoantibodies and Inflammatory Parameters in Non-infectious Scleritis

PURPOSE

Scleritis is a potentially blinding disorder, with highly unpredictable course and outcome. We analyzed the prevalence and clinical relevance of autoantibodies and inflammatory parameters in non-infectious scleritis.

METHODS

Retrospective analysis of laboratory findings in all consecutive patients at the department of Ophthalmology of the Erasmus MC with non-infectious scleritis.

RESULTS

We included 81 patients with non-infectious scleritis. A systemic autoimmune disease was present in 46%. Positive anti-nuclear antibodies were found in 30%, anti-neutrophil cytoplasmic antibodies were positive in 19%, and the presence of rheumatoid factor was shown in 17%. The aforementioned autoantibodies, as well as inflammatory parameters, failed to show prognostic clinical value. In contrast, anti-citrullinated peptide antibodies (ACPA), found in 9% of scleritis patients, were significantly associated with the development of scleral necrosis (P = .01).

CONCLUSIONS

The presence of ACPA in patients with non-infectious scleritis was associated with the development of scleral necrosis.

[Colchicine and non-severe ocular inflammation excluding Behcet's disease: 16 cases and literature review]

INTRODUCTION

Colchicine is a narrow therapeutic margin drug that does not have the adverse effects of corticosteroids and immunosuppressants. Its use in non-severe ocular inflammatory disease excluding Behcet's disease has not been studied.

METHODS

We included patients seen in the internal medicine department of Dijon University Hospital consecutively between September 2020 and September 2021 if they had received colchicine during their pathology. Patients with suspected Behçet's disease were excluded. Treatment efficacy was studied in patients with at least one year of disease progression who had received more than one year of colchicine. Successful treatment was defined as a 50 % reduction in the number of annual relapses on colchicine.

RESULTS

Sixteen patients were included (9 women and 7 men). They had recurrent anterior uveitis (n=10), recurrent scleritis (n=5) and intermediate uveitis. Opthalmological involvement was neither severe nor complicated. All patients combined, the annual relapse ratio (ARR) decreased from 1.8 (0.8-3.5) to 0.3 (0-1.6), (P=0.06). Colchicine was considered effective in three of 10 analyzable patients. In only one patient, treatment was stopped for adverse effects after six weeks.

CONCLUSION

In view of the interesting benefit-risk ratio of colchicine, it seems appropriate to focus on this molecule in non-granulomatous anterior uveitis and non-severe recurrent scleritis.

Characteristics and Outcomes of Patients with Scleritis in the IRIS® Registry (Intelligent Research in Sight) Database

PURPOSE

To report patient characteristics and factors associated with poor visual acuity and abnormal intraocular pressure (IOP) in patients with scleritis in the American Academy of Ophthalmology's IRIS® Registry (Intelligent Research in Sight).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients in the IRIS Registry with at least 3 office visits associated with an International Classification of Diseases scleritis code from 2013 through 2019.

METHODS

We evaluated demographic and clinical characteristics in scleritis and scleritis subtype cohorts. We conducted Cox proportional hazards and multiple logistic regression analyses to assess associations with poor best-corrected visual acuity (BCVA), vision loss, and IOP abnormalities.

MAIN OUTCOME MEASURES

Patient characteristics, BCVA of 0.6 logarithm of the minimum angle of resolution (logMAR) or more, BCVA worsened by more than 3 logMAR units 6 months after presentation, IOP of 30 mmHg or more, and IOP of 5 mmHg or less.

RESULTS

In this cohort of 111 314 patients with scleritis, the mean ± standard deviation age was 58.5 ± 16.6 years, 66% were women, and 30% had bilateral scleritis. Patients with scleromalacia perforans were older and more likely to have bilateral disease. Multiple logistic regression analysis identified factors with increased odds for poor presenting BCVA (older age, male sex, Black race, Hispanic ethnicity, smoking, and scleritis subtypes) and at least 3 lines of vision loss 6 months after initial scleritis diagnosis (older age, smoking, and anterior scleritis). Cox proportional hazards regression modeling of BCVA of 0.6 logMAR or more showed older age (adjusted hazard ratio [aHR] per 10-year unit, 1.11), Black race (aHR, 1.19), Hispanic ethnicity (aHR, 1.22), active smoking (aHR, 1.39), former smoking (aHR, 1.26), and certain scleritis subtypes increase the risk of poor visual acuity development (P < 0.001 for all). Older age, male sex, Black race, Hispanic ethnicity, smoking, and scleritis subtypes increased the odds of IOP abnormality.

CONCLUSIONS

Older age, Black or Hispanic ancestry, smoking, and specific scleritis subtypes are risk factors for worse visual and IOP outcomes in patients with scleritis in the IRIS Registry. Closer follow-up may be appropriate for older, Black, or Hispanic patients with scleritis; smokers should receive smoking cessation assistance.

A case of bilateral sclerouveitis with secondary glaucoma right eye

Infectious scleritis is rare and most commonly herpetic in origin. We report an unusual bilateral subacute presentation of scleritis with uveitis and glaucoma which responded to treatment with acyclovir. A 47-year-old male coast guard personnel presented with 2 months history of bilateral red eye. He was initially managed elsewhere as conjunctivitis, and on examination had bilateral diffuse redness of the eyes persisting with phenylephrine, with scleral edema and mild globe tenderness. Investigations for underlying autoimmune systemic illness were normal. He showed inadequate response to topical steroids and cycloplegics and developed uveitis and glaucoma while on steroids. He was then given tablet acyclovir with antiglaucoma topical medications with which he showed rapid response and complete resolution. The case is being reported for highlighting this unusual bilateral presentation of scleritis with uveitis and glaucoma with possible viral etiology.

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.

Sclerouveitis with exudative retinal detachment associated with chronic myelomonocytic leukemia

Purpose

To describe a case of sclerouveitis with exudative retinal detachment in a patient with chronic myelomonocytic leukemia.

Observations

An 82-year-old woman with chronic myelomonocytic leukemia (CMML) presented with acute painful right eye redness and decreased visual acuity. Examination revealed right eye anterior and posterior scleritis with exudative retinal detachment, as well as 2+ anterior chamber cell in the right eye and 0.5+ in the left eye. Workup was negative for infectious etiologies and chest imaging revealed no pulmonary nodules. She was treated with prednisolone drops and a tapering course of oral prednisone as she started therapy with ruxolitinib for CMML. Inflammation resolved with treatment, and she remained quiet off steroids while on ruxolitinib.

Conclusions and importance

This is the first case report to specifically describe sclerouveitis associated with CMML, despite the known association of this cancer with various inflammatory manifestations. This case demonstrates that CMML may present with scleritis and uveitis, and should be considered as the underlying etiology of inflammatory eye disease in patients with a diagnosis of CMML.

Clinical Profile of Scleritis Presenting for the First Time in the Elderly

PURPOSE

To analyze clinical characteristics of scleritis in elderly patients and also compare the data with relatively younger patients with scleritis (<60 years).

METHOD

Retrospective analysis of medical records of patients with scleritis who visited a tertiary eye care centre between 2008 and 2018.

RESULT

Scleritis in ≥60 years accounted for 3% of the total scleritis cases. The mean age of the patients was 67 ± 6 years, and a female (66%) predominance was noted. Of the 44 elderly patients with scleritis, 48% were 66-70 years of age and 20% were above 70 years of age. Diffuse scleritis was the most common subtypes followed by necrotizing scleritis (35%). Overall, 32% of elderly patients with scleritis had underlying disease and the most common systemic association was granulomatous with polyangiitis. When compared with a subset of patients (<60 years of age), the elderly group showed higher rate of recurrences and complications.

CONCLUSION

Scleritis in elderly patients is relatively rare but can have a higher recurrence rate with a increased complications.

Demographic and clinical features of pediatric uveitis and scleritis at a tertiary referral center in China

Background

To analyse demographic, clinical features, treatment and therapeutic outcomes of pediatric uveitis and scleritis patients.

Subjects

The clinical records of pediatric uveitis and scleritis cases between January 2012 and December 2020 at a tertiary uveitis service center in Tianjin Medical University Eye Hospital (TMUEH) were reviewed.

Results

In total, 209 patients (337 eyes) were included, 49.3% were male. The median onset age was 9.0 (IQR, 7.0–12.0) years. Chronic uveitis and scleritis accounted for 86.1%. Panuveitis (29.2%), anterior uveitis(29.2%), and intermediate uveitis (22.0%) were the most common presentations. The most common diagnoses were idiopathic (71.3%), JIA (8.1%), and infectious uveitis (4.8%). At baseline, 40.7% patients received oral corticosteroid therapy; during follow-up, corticosteroids (66.0%), disease-modifying antirheumatic drugs (61.2%), and biologic agents (35.4%) were the mainstay. Posterior synechia (26.1%) and cataracts (25.5%) were the most common complications. In acute cases, the median best corrected visual acuity (BCVA) was 0.99 (IQR, 0.5–1.0) at baseline and 0 (IQR, 0–0) at last follow-up; in chronic cases, the median BCVA improved from 1.09 (IQR, 0.5–2.0) to 0.27 (IQR, 0–0.5), with anterior chamber cell grade significantly declining. Ten eyes underwent cataract surgery during regular follow-up and achieved satisfactory long-term visual outcomes and decreased burden of immunosuppressants. The incidence of steroid-induced ocular hypertension was 41.0%, and children with frequent instillation of eyedrops were at high risk.

Conclusions

Most cases were of chronic uveitis and scleritis requiring long-term systemic immunosuppressive therapies in pediatric uveitis and scleritis in China. Good management of complications is important for long-term prognosis.

Clinical Profile, Systemic Association, Treatment and Visual Outcome of Patients with Scleritis in an Eye Care Center in Mexico City

AIMS

To describe demographic and clinical characteristics as well as etiologies and visual outcomes of patients with scleritis.

METHODS

This is a descriptive, observational and retrospective study. We reviewed the electronic health records of patients with diagnosis of scleritis, who presented at the Institute of Ophthalmology Conde de Valenciana from January 2009 to December 2019.

RESULTS

The cohort consisted of 162 patients with mean follow-up of 33.7 months. Mean age of scleritis presentation was 53.8 years. The most common type of scleritis was anterior nodular in 67 patients (41.3%). Most cases were idiopathic (52.4%). Visual outcomes were worse in anterior necrotizing scleritis. The most used drugs were oral NSAIDs and corticosteroids.

CONCLUSION

The visual outcome in most patients is favorable, however it depends on scleritis type and etiology, with worse prognosis in anterior necrotizing scleritis forms and associated with autoimmune or systemic diseases.

Subconjunctival Rituximab Administration for the Treatment of Scleritis

PURPOSE

Scleritis is a sight-threatening inflammation, which is commonly accompanied by severe complications. Aggressive systemic immunosuppressive treatment, which is frequently needed, can be associated with serious complications, and might therefore be (temporarily) contraindicated.

METHODS

We report on the outcomes of three patients with severe, active, non-infectious scleritis, refractory or intolerant to systemic treatment, who received subconjunctival rituximab (RTX) injections. A dose of 2.5 to 7.5 mg was administered after topical anesthesia, and follow-up varied from 8 to 10 months.

RESULTS

Subconjunctival RTX showed minimal to no effect on subjective symptoms, clinical features and/or ultrasound images. No serious adverse effects occurred.

CONCLUSION

Further studies are needed to assess the effect of local administration of RTX in scleritis, but our limited observation is not promising.

Giant cell arteritis and scleritis: A rare association

Background

Giant cell arteritis (GCA) is a vasculitis of the large and medium-sized arteries in the elderly whose ischemic complications adversely affect the eye. The irreversible loss of visual acuity is most often related to acute anterior ischemic optic neuropathy. Very few cases of scleritis have been described in the literature.

Case Presentation

The patient presented an obvious case of giant cell arteritis, initially revealed by an ophthalmologic involvement in the form of posterior scleritis, an ear, nose, and throat (ENT) involvement with vestibular and neurological involvement with a type of peripheral neuropathy, all evolving in the context of a weight loss of 8 kg and a marked biological inflammatory syndrome. The patient presented several relapses of giant cell arteritis in the form of several episodes of anterior and posterior, right and left, and even bilateral, isolated scleritis without any other clinical or biological abnormalities, always in conjunction with a decrease in corticosteroid therapy. In the presence of corticosteroid dependence and resistance to methotrexate, tocilizumab was initiated.

Conclusion

The therapeutic management of scleritis associated with giant cell arteritis is difficult. In the absence of a codified scheme, the treatment remains empirical, based on the experience of the various teams. In this context, biotherapies (anti-IL6 type, such as tocilizumab) are increasingly used.

Vision-related quality of life and psychosocial well-being of patients with episcleritis and scleritis: a neglected essence?

Background

To assess the change in vision-related quality of life and psychosocial well-being of the patients with episcleritis and scleritis patients before and after treatment.

Results

This one-and-a-half-year prospective study was conducted among 76 eyes of 71 new patients of episcleritis and scleritis. A structured questionnaire was used to assess the visual and to analyze the change in effect size. The male-to-female ratio was 1:1.536. Episcleritis was seen in 41 cases (57.7%) while scleritis was seen in 30 cases (42.3%). Patients with episcleritis had statistically significant improvement in general function score (GF) (p < 0.05) using paired t-test. The effect size showed medium improvement (approximately 0.5). Whereas there was no statistically significant change in psychosocial impact (PI), visual symptoms (VS) scoring, and a total score (p < 0.05) using paired t-test. The effect size showed no improvement for PI and total score and small improvement for VS score. Patients with scleritis had statistically significant improvement in general function score (GF), visual symptoms (VS) scoring and total score (p < 0.05) using paired-t-test. The effect size showed medium improvement (approximately 0.5) for general function score (GF) and total score. However, the effect size showed only a small improvement (approximately 0.2) for psychosocial impact (PI) score.

Conclusions

VisionRelated Quality of Life of patients with scleritis showed significant improvement following treatment unlike episcleritis indicating scleritis more adversely affecting psychosocial well-being.

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.

Posterior Scleritis as a Paraneoplastic Syndrome in Colon Cancer: A Case Report

This study presents a rare case of unilateral posterior scleritis as an ophthalmic manifestation of a paraneoplastic syndrome. A 61-year-old man presented to our department complaining of gradual worsening of vision in his left eye. Visual acuity was 10/10 and 3/10 in his right and left eye, respectively. He also mentioned that he experienced posterior ocular pain while sleeping at night, but was otherwise asymptomatic. His past ophthalmic and medical history were clear. A thorough clinical, imaging (fundus photography, optical coherence tomography, fluorescein angiography, and B-scan), and laboratory investigation was carried out. A diagnosis of posterior scleritis was made, but no obvious cause or underlying disease was identified even after a thorough systematic assessment. Regular follow-up within the next few months did not reveal any further pathological findings. Finally, 6 months after the initial presentation, the patient was diagnosed with colon cancer. Posterior scleritis can present as an ophthalmic manifestation of a paraneoplastic syndrome in patients with an underlying malignancy, even months before the presentation of systemic symptoms and diagnosis of the underlying disease. In conclusion, in patients (especially older adults) with posterior scleritis, the possibility of a malignant neoplasia must not be ignored or underestimated (paraneoplastic syndrome).

Chronic unilateral anterior scleritis, think about a herpetic origin: A case report

Scleritis is a very heterogeneous group of diseases responsible for ocular inflammation of varying severity, the evolution and prognosis of which depend on the etiology but also on the appropriate treatment. We report the case of a 15-year-old female patient, without any notable general history, followed in consultation for 3 months for a nodular scleritis not improving under usual treatments. She was reconsulted when her symptoms worsened and the examination revealed a minimal reaction of the anterior chamber, in addition to the nodular scleritis localized in the temporal region, with the notion of a vesicular eruption in the perioral region on the same side of the ocular involvement and preceding the ocular symptoms by one week, consistent with a cutaneous herpes. The patient was put on oral Aciclovir (800 mg, 3 times a day) with a clear improvement marked by a decrease in pain and redness, which improved again after the introduction of oral corticoids. The existence of an extraocular sign of herpes and the good response to antiviral treatment, thus confirming the herpetic etiology of this chronic nodular scleritis. Scleritis is caused by herpes in about 5% of cases. The clinical picture is either ophthalmic herpes zoster with associated scleritis (VZV), or diffuse anterior scleritis, unilateral in 80% of cases, related to herpes simplex. The diagnosis can be confirmed by local swabs, or more often by an antiviral therapeutic test.

Bilateral infectious scleritis from Histoplasma capsulatum in an immunosuppressed uveitis patient

Purpose

To describe a case of bilateral infectious scleritis secondary to Histoplasma capsulatum in the setting of a locally and systemically immunosuppressed patient.

Observations

A 45-year-old man with HLA-B27 associated ankylosing spondylitis and anterior uveitis on systemic secokinumab, underwent bilateral cataract extraction which required extensive peri-operative steroids, including intravitreal triamcinolone, topical prednisolone, and oral prednisone. Six weeks after cataract surgery, the patient presented with mild eye irritation and was found to have bilateral subconjunctival purulence and necrosis. Histoplasma capsulatum was identified on fungal cultures and confirmed by DNA probe. The patient was treated with fortified amphotericin drops and oral itraconazole with complete resolution of scleritis.

Conclusion and importance

H. capsulatum is a rare cause of infectious scleritis that must be considered in our immunosuppressed and post-surgical patients.

Radiology of Abnormal Globe Contour

The orbits are easily identified on routine computed tomography (CT) and magnetic resonance imaging (MRI) imaging of the head and neck. Although there are many structures within the orbits, the overall structure of the globe is the most noticeable and can be an important source for pathology. In particular, many disease processes alter globe morphology and it is imperative that the radiologist be aware of not only the most common, but uncommon etiologies as well. This article provides an image-rich review of the wide range of emergent and non-emergent pathology that can result in altered globe contour.

The clinical presentation and treatment outcomes of ocular tuberculosis: a 5-year experience in an endemic area

PURPOSE

To report the clinical presentations of ocular tuberculosis infection (OTB) and the treatment regimen and outcome in an endemic area.

METHODS

This is a retrospective case series of patients with presumed OTB treated in a tertiary teaching hospital in Hong Kong in 2014-2019.

RESULTS

Among the nineteen patients recruited, the most common clinical presentation of OTB was retinal vasculitis (42.1%), followed by scleritis, intermediate uveitis, and choroidal tuberculoma (15.8% respectively). 94.7% and 94.4% of the subjects were treated with ATT and steroid, respectively, and 31.6% were put on systemic immunosuppressant prior to the initiation of ATT. Apart from those suffering from intermediate uveitis, most demonstrated good clinical response within 8 weeks of ATT initiation.

CONCLUSION

Ocular involvement of TB has been increasingly recognized, especially in endemic regions like Hong Kong. High index of suspicion is recommended for OTB in typical clinical phenotypes or recurrent/resistant ocular inflammation unresponsive to conventional therapy. TB retinal vasculitis was the most common presentation of OTB in this study and OTB generally requires treatment with either regional or systemic steroid together with ATT.

Optical Coherence Tomography Findings in Nodular Anterior Scleritis due to Post-Streptococcal Syndrome

Purpose

To report a case of nodular anterior scleritis due to poststreptococcal syndrome using optical coherence tomography imaging.

Case Report

A 41-year-old woman with a history of acute rheumatic fever presented with a nodular anterior scleritis. Common causes were excluded. Optical coherence tomography of sclera showed enlarged vessels, inflammatory infiltrates, separated fibers, and a serous detachment. Laboratory investigations showed an elevated erythrocyte sedimentation rate, raised anti-streptolysin O titer, and the presence of group A streptococcus in the throat. The scleritis rapidly improved with penicillin treatment.

Conclusion

Poststreptococcal syndrome should be considered in the etiology of non-necrotizing anterior scleritis.

Health system wide "big data" analysis of rheumatologic conditions and scleritis

BACKGROUND

The development of scleritis in the setting of autoimmune conditions has been well documented. Prior series have assessed the relationship between systemic autoimmune disorders and scleritis only in patients referred for rheumatologic or ocular inflammation. This can lead to a referral bias. We reviewed all charts within the electronic medical record (EMR) of a health system for patients with systemic autoimmune and scleritis diagnoses to determine the prevalence of both and which disorders had the highest relative risk of developing scleritis.

METHODS

The EMR was searched for scleritis and systemic inflammatory diagnoses in the past medical history and diagnosis tabs, and for associated disease specific laboratory values. The intersection of scleritis and systemic inflammatory conditions was assessed through searching both SNOMED Clinical Terminology and ICD-10 codes for diagnoses. The prevalence of each autoimmune disorder, scleritis prevalence, the percentage of patients with an autoimmune condition having scleritis, the percentage of patients with scleritis having an autoimmune condition; the relative risk (RR) of scleritis patients having a specific autoimmune disorder were calculated.

RESULTS

A total of 5.9 million charts were searched with autoimmune conditions identified in 148,993 patients. The most common autoimmune conditions overall were HLA-B27-associated diseases (n = 26,680; prevalence 0.45%); rheumatoid arthritis (RA)(N = 19,923; prevalence 0.34%). Conversely, 2702 patients were identified with scleritis (prevalence 0.05%), of which 31.4% had an associated autoimmune condition. Patients with RA represented the highest percentage of patients with an autoimmune condition having scleritis. Granulomatosis with polyangiitis (GPA) represented the highest the percentage of patients with scleritis having an autoimmune condition. Sjogrens was the third most common condition associated with scleritis- making up 4.5% of cases. An association with juvenile idiopathic arthritis (JIA) was seen in 0.3% of patients.

CONCLUSIONS

While this is the largest retrospective review examining the association between autoimmune disease and scleritis, the findings are similar to prior studies with nearly a third of scleritis patients having an underlying autoimmune diagnosis. Limitations of the study included accurate chart coding; having laboratory results within the searchable EMR. Future research is needed to delineate associations of systemic disease with the anatomic location of scleritis using EMR.

The haplotypes of various TNF related genes associated with scleritis in Chinese Han

Background

Several studies have stated that TNF-α participates in the pathogenesis of scleritis, but also in several systemic autoimmune diseases and vasculitis, of which some are associated with scleritis. Earlier GWAS and SNP studies have confirmed that multiple SNPs of TNF related genes are associated with many immune-mediated disorders. The purpose of this study was to examine the association of TNF related gene polymorphisms with scleritis in Chinese Han. A case-control study was carried out in 556 non-infectious scleritis cases and 742 normal controls. A total of 28 single-nucleotide polymorphisms (SNPs) were genotyped by the iPLEXGold genotyping assay.

Results

No significant correlations were seen between the individual SNPs in the TNF related genes and scleritis. Haplotype analysis showed a significantly decreased frequency of a TNFAIP3 TGT haplotype (order of SNPs: rs9494885, rs3799491, rs2230926) (Pc = 0.021, OR = 0.717, 95% CI = 0.563–0.913) and a significantly increased frequency of a TNFSF4 GT haplotype (order of SNPs: rs3850641, rs704840) (Pc = 0.004, OR = 1.691, 95% CI = 1.205–2.372) and TNFSF15 CCC haplotype (order of SNPs: rs6478106, rs3810936, rs7865494) (Pc = 0.012, OR = 1.662, 95% CI = 1.168–2.363) in patients with scleritis as compared with healthy volunteers.

Conclusions

This study reveals that a TGT haplotype in TNFAIP3 may be a protective factor for the development of scleritis and that a GT haplotype in TNFSF4 and a CCC haplotype in TNFSF15 may be risk factors for scleritis in Chinese Han.