Treatment options for necrotizing scleritis in rheumatoid arthritis patients

ABSTRACT

Introduction

Necrotizing scleritis is more likely to be associated with severe pain, poor visual outcomes, increased mortality, and autoimmune disease such as rheumatoid arthritis. The advent of targeted biologic therapy has revolutionized the treatment of rheumatic diseases, and these medications are currently being explored for ocular inflammatory disease – including necrotizing scleritis which is often refractory to conventional immunomodulatory therapies.

Areas covered

The authors review available therapies for scleritis, including topical treatments and systemic immunosuppressive agents. Particular attention is given to CD20 inhibitors, TNFα inhibitors, IL6 inhibitors, and IL1 inhibitors as they are increasingly used to treat ocular inflammatory disease. Finally, the authors touch on surgical techniques for reinforcing necrotic areas of sclera.

Expert opinion

The authors advocate for a standardized clinical grading system of scleritis to facilitate large scale, multicenter, and randomized clinical trials evaluating the efficacy of treatment regimens for noninfectious scleritis – particularly for TNFα inhibitors, anti-IL6 agents, and combinations of conventional medications. For noninfectious and recalcitrant necrotizing scleritis, the authors recommend initial therapy with mycophenolate mofetil, followed by a TNFα inhibitor or rituximab. As a last resort for severely recalcitrant and/or globe threatening cases, alkylating agents may be necessary.

KEYWORDS:

• Immunology
• necrotizing scleritis
• ocular inflammation
• rheumatoid arthritis
• scleritis

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Article highlights

• The authors provide a review of the epidemiology and pathophysiology of scleritis and rheumatoid arthritis.

• The authors summarize the published data regarding treatment of scleritis, with a focus on necrotizing scleritis due to rheumatoid arthritis.

• The authors discuss potential future directions for scleritis refractory to conventional treatment options.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.