What are the treatment guidelines for posterior scleritis?

From the Guidelines

Posterior scleritis treatment should primarily involve corticosteroids, with other systemic immunosuppressive medication considered for cases that are resistant or require steroid-sparing therapy, as indicated in the most recent evidence 1. The treatment approach for posterior scleritis is crucial due to its potential for serious complications, including vision loss, given its impact on the posterior segment of the eye. Key characteristics of posterior scleritis include deep pain, hyperemia of the conjunctiva and large scleral vessels, painful eye movements, choroidal folds, serous retinal detachment, and optic disc edema on examination, along with fluid in the sub-Tenon space around the optic disc (T-sign) on ultrasonography, and no leakage on FA/ICGA 1. Some of the key considerations in managing posterior scleritis include:

• The use of corticosteroids as a first-line treatment, which can be administered orally or via periocular injections, depending on the severity and patient response.
• For cases that do not respond adequately to corticosteroids or where steroid use needs to be minimized, the addition of immunosuppressive agents such as methotrexate, mycophenolate mofetil, azathioprine, or cyclophosphamide may be necessary.
• Regular monitoring with B-scan ultrasonography to assess scleral thickness and the resolution of fluid, alongside clinical evaluation for signs of inflammation and vision improvement.
• The importance of managing potential side effects of long-term medication use, including regular checks on liver function, complete blood counts, and blood pressure. Given the complexity and variability in patient responses, treatment should be tailored to the individual, with adjustments made based on clinical response and the presence of any side effects. The goal is to achieve complete resolution of inflammation while minimizing the risk of complications and preserving vision.

From the Research

Posterior Scleritis Treatment Guidelines

• The treatment of posterior scleritis typically involves the use of corticosteroids, which remain the mainstay of short-term treatment 2.
• For mild to moderate scleral inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) or topical corticosteroids may be effective 2.
• In cases where there is an inadequate response or failure to provide long-term control of inflammation, corticosteroid-sparing immunosuppressive therapies may be useful 2.
• Biologic agents are increasingly being used in the management of scleritis that does not respond to conventional therapies 2.
• A study on posterior scleritis in children found that oral nonsteroidal anti-inflammatory agents alone were effective in only 8% of patients, while 92.3% of patients required oral corticosteroids 3.
• Immunosuppressive agents were required in 84.6% of patients due to relapse or intolerance to corticosteroids 3.
• The use of immunosuppression in patients with scleritis, especially those with posterior scleritis, can often achieve improvement 4.
• A retrospective chart review of patients with scleral inflammation found that 30.4% of patients with scleritis required nonsteroidal anti-inflammatory drugs, 31.9% required oral prednisone, and 26.1% required systemic immunosuppressive drugs 5.
• A review of ocular pharmacology for scleritis discussed the use of traditional anti-inflammatory agents, such as NSAIDs, steroids, and immunomodulatory therapy, as well as newer biologic therapies 6.

Treatment Approaches

• Systemic corticosteroids are often used to achieve resolution of posterior scleritis, with long-term immunosuppression required to prevent recurrence 3.
• The choice of treatment approach may depend on the severity of the disease, the presence of underlying systemic diseases, and the risk of ocular complications 4, 5.
• A multi-disciplinary approach to management, including meticulous history taking, detailed ocular examination, and a targeted array of investigations, is crucial for the management of posterior scleritis 2.

Ocular Complications

• Posterior scleritis is often associated with ocular complications, such as anterior uveitis, disc swelling, and retinal striae 3.
• The risk of ocular complications is higher in patients with necrotizing scleritis and posterior scleritis compared to those with diffuse anterior scleritis and nodular anterior scleritis 4, 5.
• The use of immunosuppression may be indicated in patients with vision-threatening complications, such as glaucoma, uveitis, and peripheral ulcerative keratitis 4.