Initial Treatment for Scleritis
Start with oral NSAIDs as first-line therapy for non-necrotizing anterior scleritis, and immediately add oral corticosteroids if NSAIDs fail after 1-2 weeks or if the disease presents as moderate-to-severe at initial evaluation. 1, 2
Immediate Diagnostic Priorities
Urgent ophthalmology consultation is mandatory to confirm the diagnosis and classify the subtype (diffuse anterior, nodular anterior, necrotizing, or posterior scleritis), as scleritis presents with severe pain, "muddy" or discolored scleral appearance, and potential vision-threatening complications requiring immediate systemic treatment. 1, 2
Distinguish scleritis from episcleritis: severe pain, deep scleral injection, and visual changes indicate scleritis, while episcleritis presents with mild pain, superficial hyperemia, and no visual disturbance. 3, 1
First-Line Treatment Algorithm
For Non-Necrotizing Anterior Scleritis (Diffuse or Nodular)
Initiate oral NSAIDs immediately as the primary therapy, with therapeutic failure rates of only 7-9% for diffuse and nodular forms. 2, 4
Monitor response over 1-2 weeks; if inadequate improvement occurs, escalate therapy without delay. 1, 2
Add oral corticosteroids as second-line therapy if NSAIDs fail or if disease severity is moderate-to-severe at presentation, using a tapering schedule over 6-8 weeks based on clinical response. 1, 2
For Necrotizing Scleritis
Bypass NSAIDs entirely (100% therapeutic failure rate) and immediately initiate high-dose systemic corticosteroids plus disease-modifying anti-rheumatic drugs (DMARDs). 2, 4
Use high-dose oral prednisone (1 mg/kg/day) or IV methylprednisolone for severe presentations. 2
Concurrently start steroid-sparing immunomodulatory therapy such as methotrexate, mycophenolate mofetil, or azathioprine, as immunosuppressive drugs show only 26% therapeutic failure as initial therapy for necrotizing disease. 2, 4
Escalation to Biologic Therapy
Anti-TNF agents (infliximab or adalimumab) are indicated when conventional DMARDs fail or for severe necrotizing scleritis. 1, 2
Infliximab dosing: 5 mg/kg IV at weeks 0,2,6, then every 8 weeks. 2
Adalimumab dosing: 40 mg subcutaneously every 2 weeks. 2
Rituximab may be an effective alternative option in refractory cases. 5
Monitoring and Coordination
Establish close coordination between ophthalmology and rheumatology/internal medicine from the outset, as scleritis may indicate underlying systemic autoimmune disease (rheumatoid arthritis in 8-15% of cases, inflammatory bowel disease, systemic lupus erythematosus, or granulomatosis with polyangiitis). 6, 5
Schedule ophthalmologic follow-up every 1-2 weeks during the acute phase, then monthly during maintenance therapy to monitor for ocular complications and adjust treatment. 2
Critical Pitfalls to Avoid
Never delay ophthalmology referral: scleritis can progress rapidly to vision loss and requires subspecialty evaluation to confirm diagnosis and guide systemic therapy. 1
Do not confuse scleritis with episcleritis: the presence of severe pain should immediately raise concern for scleritis, which requires systemic rather than topical treatment. 1, 7
Do not use NSAIDs alone for necrotizing scleritis: this subtype requires immediate immunosuppression, as NSAIDs have a 100% failure rate. 4
Address underlying systemic disease: scleritis often reflects inadequate control of associated autoimmune conditions and may be the first indicator of rheumatoid vasculitis. 3, 5