Abstract

Episcleritis and scleritis are the most common ocular inflammatory manifestation of rheumatoid arthritis. Rheumatoid arthritis (RA) accounts for 8% to 15% of the cases of scleritis, and 2% of patients with RA will develop scleritis. These patients are more likely to present with diffuse or necrotizing forms of scleritis and have an increased risk of ocular complications and refractory scleral inflammation. In this review we provide an overview of diagnosis and management of rheumatoid arthritis-associated episcleritis and scleritis with a focus on recent treatment perspectives. Episcleritis is usually benign and treated with oral non-steroidal anti- inflammatory drugs (NSAIDs) and/or topical steroids. Treatment of scleritis will classically include oral NSAIDs and steroids but may require disease-modifying anti-rheumatic drugs (DMARDs). In refractory cases, treatment with anti TNF biologic agents (infliximab, and adalimumab) is now recommended. Evidence suggests that rituximab may be an effective option, and further studies are needed to investigate the potential role of gevokizumab, tocilizumab, abatacept, tofacitinib, or ACTH gel. A close cooperation is needed between the rheumatology or internal medicine specialist and the ophthalmologist, especially when scleritis may be the first indicator of an underlying rheumatoid vasculitis.

Highlights

  • Rituximab is a monoclonal antibody that recognizes CD-20, an antibody expressed on Rituximab is a monoclonal antibody that recognizes CD-20, an antibody expressed the surface of mature B lymphocytes, approved for the treatment of moderate-to-severe on the surface of mature B lymphocytes, approved for the treatment of moderate-to-severe

  • In addition to the risk of globe perforation, the onset of necrotizing scleritis is a strong indicator that the disease has transformed into a systemic microvasculitic disease, which needs to be addressed with vigorous systemic immunomodulation [44,45]

  • There is no consensus yet as to what sequence of treatment is optimal for ocular manifestations of rheumatoid vasculitis such as necrotizing scleritis or Peripheral ulcerative keratitis (PUK)

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Summary

Introduction

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Ocular manifestations, including episcleritis, scleritis, peripheral ulcerative keratitis, and dry eye disease, can be encountered in as many as 39% of patients with RA [1]. More and more immunomodulatory medications are developed for the treatment of RA, that seem effec of 14 tive in controlling the refractory inflammation in scleritis Because of their knowledge of inflammatory disorders and immunosuppressive medications, rheumatology and internal medicine specialists may be asked for assistance in the diagnosis and management of inflammatory disorders and immunosuppressive ocular inflammation, associated with RA or not. The deepest, scleral plexus has2)a can pattern of criss-cross vessels tightly scleritis is classified into nodular Is no scleral swelling, and thelimited deep vascular plexus congested, and infiloedema and infiltration are limited to the episclera. Inflammation of sclera, and abnormal appearance ofabnormal the deep scleral vas- of

Widespread
Episcleritis
Scleritis
Biologic Response Modifiers
Rituximab
Tofacitinib
ACTH Gel
Subconjunctival Injections
Necrotizing Scleritis and Rheumatoid Vasculitis
Complications and Incidence of Resolution
Findings
Conclusions
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