What is the treatment for recurrent scleritis?

Treatment of Recurrent Scleritis

For recurrent scleritis, treatment should begin with oral non-steroidal anti-inflammatory drugs (NSAIDs) for non-necrotizing forms, while immunosuppressive therapy should be the initial choice for necrotizing scleritis, with treatment escalation based on response and underlying etiology.

Classification and Initial Assessment

Proper treatment requires identifying the type of scleritis:

• Anterior scleritis: Most common, visible inflammation
  • Non-necrotizing: Diffuse or nodular
  • Necrotizing: With or without inflammation
• Posterior scleritis: Affects posterior eye

Key Assessment Points:

• Evaluate for underlying systemic autoimmune conditions (30-40% of cases)
• Check for rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematosus, granulomatosis with polyangiitis
• Assess severity and extent of scleral involvement
• Rule out infectious causes

Treatment Algorithm for Recurrent Scleritis

1. Non-Necrotizing Scleritis (Diffuse or Nodular)

First-line therapy:

• Oral NSAIDs 1, 2
  • Therapeutic failure occurs in only 7-9% of cases with diffuse/nodular scleritis
  • Options include indomethacin, naproxen, or ibuprofen at anti-inflammatory doses

Second-line therapy (if NSAIDs fail):

• Add or substitute systemic corticosteroids 2
  • Prednisone typically starting at 1 mg/kg/day
  • Taper as soon as inflammation is controlled
  • Continue NSAIDs during taper if possible

Third-line therapy (if corticosteroids fail or for steroid-sparing):

• Immunomodulatory agents 1, 3
  • Methotrexate, azathioprine, or mycophenolate mofetil
  • For refractory cases: TNF inhibitors (infliximab, adalimumab)
  • Rituximab may be effective in rheumatoid arthritis-associated scleritis 3

Adjunctive local therapy:

• Topical corticosteroids may be tried but have limited efficacy (47% success rate) 4
• Subconjunctival steroid injections for localized non-necrotizing scleritis 5

2. Necrotizing Scleritis

First-line therapy:

• Immunosuppressive drugs 2
  • NSAIDs alone have 100% failure rate in necrotizing scleritis
  • Systemic corticosteroids alone have 91% failure rate
  • Immunosuppressive drugs have only 26% failure rate as initial therapy

Specific regimens:

• High-dose systemic corticosteroids plus immunosuppressive agent
• Consider pulse methylprednisolone for severe cases
• Cyclophosphamide for vasculitis-associated necrotizing scleritis
• Biologic agents (rituximab, infliximab) for refractory cases 1, 3

Treatment of Underlying Conditions

• Rheumatoid arthritis: Coordinate with rheumatologist to optimize disease-modifying antirheumatic drugs (DMARDs) 3
• Inflammatory bowel disease: Anti-TNF monoclonal antibodies preferred over etanercept 6
• Ankylosing spondylitis with recurrent iritis: Infliximab or adalimumab preferred over etanercept 6

Monitoring and Follow-up

• Frequent follow-up until inflammation is controlled
• Monitor for medication side effects
• Assess for complications (cataract, glaucoma, corneal thinning)
• Coordinate care with specialists treating underlying systemic disease

Important Considerations

• Recurrent scleritis may indicate inadequate treatment of underlying systemic disease
• Necrotizing scleritis requires aggressive therapy to prevent vision loss
• Patients with rheumatoid arthritis-associated scleritis have higher risk of ocular complications and refractory disease 3
• Close cooperation between ophthalmologist and rheumatologist/internist is essential, especially when scleritis may be the first indicator of underlying rheumatoid vasculitis 3

Pitfalls to Avoid

1. Delaying immunosuppressive therapy in necrotizing scleritis
2. Inadequate treatment of underlying systemic disease
3. Prolonged corticosteroid use without steroid-sparing agents
4. Failure to monitor for medication side effects
5. Missing infectious causes of scleritis (requires different treatment approach)

Early, appropriate treatment reduces both ocular and systemic morbidity in patients with recurrent scleritis.