Recurrent Scleritis Research Articles

A Case of a Patient with Refractory Scleritis Treated with Rituximab

Purpose: We report a patient with refractory scleritis effectively treated with rituximab after ineffective, initial, conventional immunosuppressive therapy.Case summary: A 58-year-old woman with no specific medical history presented with recurrent scleritis of the right eye. Her uncorrected visual acuities in both eyes were 20/20, and a blood test for cytoplasmic antineutrophil cytoplasmic antibody (C-ANCA) was positive. Systemic and subconjunctival steroid treatments were not effective, and the scleritis recurred even after further treatment with oral cyclosporin A and mycophenolate mofetil. After intravenous administration of infliximab (5 mg/kg), slight improvement was noted, but the recurrence continued. Thereafter, the visual acuity of the right eye decreased markedly because of choroidal and serous retinal detachment caused by posterior scleritis. Immunohistochemically, the inflamed scleral tissue showed considerable B-cell infiltration. Accordingly, intravenous rituximab (1 g) was administered twice at a 2-week interval. The scleral vessel engorgement and inflammation dramatically improved, and the scleritis became well-controlled without recurrence for more than 8 months.Conclusions: Intravenous rituximab may be helpful when encountering scleritis refractory to conventional immunomodulation therapy.

Colchicine et inflammation oculaire non sévère hors maladie de Behcet : 16 cas et revue de la littérature

IntroductionColchicine is a narrow therapeutic margin drug that does not have the adverse effects of corticosteroids and immunosuppressants. Its use in non-severe ocular inflammatory disease excluding Behcet's disease has not been studied. MethodsWe included patients seen in the internal medicine department of Dijon University Hospital consecutively between September 2020 and September 2021 if they had received colchicine during their pathology. Patients with suspected Behçet's disease were excluded. Treatment efficacy was studied in patients with at least one year of disease progression who had received more than one year of colchicine. Successful treatment was defined as a 50 % reduction in the number of annual relapses on colchicine. ResultsSixteen patients were included (9 women and 7 men). They had recurrent anterior uveitis (n=10), recurrent scleritis (n=5) and intermediate uveitis. Opthalmological involvement was neither severe nor complicated. All patients combined, the annual relapse ratio (ARR) decreased from 1.8 (0.8–3.5) to 0.3 (0–1.6), (P=0.06). Colchicine was considered effective in three of 10 analyzable patients. In only one patient, treatment was stopped for adverse effects after six weeks. ConclusionIn view of the interesting benefit-risk ratio of colchicine, it seems appropriate to focus on this molecule in non-granulomatous anterior uveitis and non-severe recurrent scleritis.

Presumed tuberculosis-related scleritis

AimsTo evaluate the clinical characteristics and therapeutic outcome of patients with recurrent scleritis of unknown demonstrable aetiology and positive QuantiFERON-TB Gold In-Tube test (QFT).MethodsRetrospective chart review of the demographic, clinical,...

IgG4-related disease presenting as recurrent scleritis combined with optic neuropathy

BackgroundWe report a case of atypical presentation of IgG4-related disease (IgG4-RD) with recurrent scleritis and optic nerve involvement.Case presentationA 61-year-old male presented with ocular pain and injection in his left eye for 2 months. Ocular examination together with ancillary testing led to the diagnosis of scleritis, which relapsed in spite of several courses of steroid treatment. After cessation of steroid, the patient complained of severe retro-orbital pain and blurred vision. His best corrected vision was count finger, the pupil was mid-dilated and a relative afferent pupillary defect was found. Funduscopic examination demonstrated disc swelling. Magnetic resonance imaging (MRI) showed enhancing soft tissue encasing the left globe, medial rectus muscle and optic nerve. Systemic work-up revealed multiple nodules in right lower lung and a biopsy showed histopathological characteristics of IgG4-RD. Long-term treatment with corticosteroids and a steroid-sparing agent (methotrexate) led to significant improvement in signs and symptoms with no recurrence for 2 years.ConclusionsThis case highlights the significance of IgG4-RD in the differential diagnosis of recurrent scleritis. IgG4-RD may cause optic neuropathy resulting in visual loss. Early diagnosis and proper treatment can prevent irreversible organ damage and devastating visual morbidity.

Recurrent scleritis as a presenting manifestation of asymptomatic occult Takayasu arteritis.

Recurrent scleritis as a presenting manifestation of asymptomatic occult Takayasu arteritis.

A Case of Recurrent Scleritis Associated with Menstrual Cycle

A Case of Recurrent Scleritis Associated with Menstrual Cycle

Suture Trabeculotomy Ab Interno for Secondary Glaucoma Combined With Scleromalacia

To report 2 cases of secondary glaucoma combined with scleromalacia that were successfully treated with trabeculotomy ab interno. Retrospective case report : Trabeculotomy ab interno was used to treat secondary glaucoma combined with scleromalacia, which occurred due to refractory scleritis, in 2 cases. In case 2, goniosynechialysis was performed before the trabeculotomy to identify the trabecular meshwork. The sclera and conjunctiva were not incised in either case. The patients' postoperative intraocular pressure (IOP) levels (which were achieved without medication) were lower than their preoperative IOP levels (which were recorded during the administration of the maximum tolerable medication dosage); that is, they had dropped from 24 to 12 mm Hg in case 1 and from 33 to 11 mm Hg in case 2 by 12 postoperative months. No recurrent scleritis or postoperative worsening of the patient's scleromalacia was seen in either case. Trabeculotomy ab interno is a very valuable treatment for secondary glaucoma combined with scleromalacia.

Intraocular pressure elevation from topical difluprednate use

Introduction Difluprednate ophthalmic emulsion 0.05% (Durezol™, Alcon, Fort Worth, Texas) is a topical difluorinated derivative of prednisolone with potent anti-inflammatory activity. Difluprednate 0.05% has a reported associated increase in intraocular pressure (IOP) in 3% of patients. Although the occurrence may be low, the possible elevation in IOP may be substantially higher than commonly encountered with other topical steroids. Case Reports A 49-year-old black man presented with a traumatic anterior uveitis recalcitrant to traditional prednisolone acetate 1% treatment. The patient was switched to difluprednate 0.05% in an attempt to better control the ocular inflammation. Although the patient did not exhibit an IOP response after 4 weeks of treatment with prednisolone acetate 1%, he did experience a pressure response within 2 weeks of initiating difluprednate treatment, resulting in an IOP increase from 9 mmHg to 48 mmHg with subsequent microcystic edema. A 44-year-old black woman presented with recurrent scleritis resistant to topical prednisolone acetate, loteprednol etabonate, and oral nonsteroidal anti-inflammatory therapy. Topical loteprednol 0.5% was replaced by difluprednate 0.05%. All evidence of ocular inflammation was eradicated with the changed therapy. IOP rose in the difluprednate-treated eye from 18 mmHg to 34 mmHg over the course of 18 days. In both cases, the IOP elevation was managed rapidly with the discontinuation of difluprednate and temporary use of IOP-reducing agents with no lasting adverse effects. Conclusion Difluprednate 0.05% is a new topical therapeutic option indicated for the treatment of inflammation and pain management associated with ocular surgery with an off-label potential for treatment of other anterior segment inflammatory conditions. However, clinicians need to be aware of the potential risk for significant and potentially rapid onset of IOP increase with this medication and manage patients accordingly.

Recurrent Conjunctivitis and Scleritis Secondary to Coexistent Conjunctival Pemiphigus Vulgaris and Cryptic Herpes Simplex Infection: A Case Report

Purpose: To report recurrent conjunctivitis and scleritis secondary to coexistent conjunctival pemiphigus vulgaris and cryptic herpes simplex infection.Design: Case report. Methods: Retrospective review.Results: A 54-year-old woman presented with recurrent left eye irritation and redness. Four years earlier, she was diagnosed (biopsy) with cutaneous pemphigus vulgaris requiring immunomodulatory therapies. She was receiving oral acyclovir for recurrent genital herpes and intravenous immunoglobulin for pemphigus. Examination revealed unilateral necrotizing scleritis and conjunctivitis. Immunohistochemical staining of biopsies demonstrated conjunctival pemphigus and herpes in conjunctiva and sclera. Valacyclovir therapy brought resolution.Conclusion: Cryptic ocular herpes may confound matters in someone with an autoimmune disease thought to be the sole source of ocular inflammation. Immunohistochemical analysis can resolve the mystery.

Point Counter-Point

We read with interest the article “Another case of bisphosphonate-induced orbital inflammation” (1). We commend the authors for a comprehensive appraisal that included detailed clinical and radiological documentation and establishment of a causal relationship between the offending drug and the clinical findings. However, we seek to refute the assertion that this case represents the first instance of orbital inflammation following bisphosphonate treatment of osteoporosis. We reported 3 menopausal middle-aged women taking alendronate (Fosamax; Merck, Whitehouse Station, NJ) for osteoporosis, 2 of whom developed manifestations consistent with orbital inflammation: myositis and posterior scleritis (2). Causal association was established similarly by the temporal relation with commencement and withdrawal of the drug. Subsequent reports of orbital inflammation associated with various bisphosphonates administered for osteoporosis have appeared in the literature and online (3-5). Indeed, some of these reports cite our original article. Most of these cases have responded well to drug withdrawal and systemic corticosteroid therapy. Of note, rechallenge with intravenous zoledronate produced a recurrence (3). Fraunfelder et al (6) likewise observed recurrent scleritis on rechallenge with pamidronate. We believe that this association with variants of nonspecific orbital inflammation, while uncommon, probably occurs more frequently than is recognized or reported. A variety of ocular inflammatory manifestations are present in an idiosyncratic manner with different generations and modes of administration of bisphosphonates. Since osteoporosis and autoimmune ocular diseases occur most commonly in middle-aged women, it is important that ophthalmologists are cognizant of the association of ocular and orbital inflammation with this class of drugs. Where a positive history is obtained, we urge consideration of drug withdrawal in the management plan. Joyce N. Mbekeani, FRCS, FRCOphth Albert Einstein College of Medicine, Bronx, New York Thomas L. Slamovits, MD Albert Einstein College of Medicine, Bronx, New York [email protected]

A Case of Recurrent Posterior Scleritis With Hyperthyroidism in Both Eyes

Purpose: Posterior scleritis is known to be a rare disease. The authors of the present study herein report a case of posterior scleritis, which occurred in a patient's eye, accompanied by hyperthyroidism and recurring in the other eye one year later. Case summary: A 39-year-old female patient visited the hospital for ocular pain in the left eye and a headache. The patient was diagnosed with posterior scleritis through fundus examination, ultrasonography, CT and MRI, and an effective outcome of treatment was obtained by oral administration of methylprednisolone. Four months after discharge, the patient received left subtotal thyroidectomy for thyroid papillary cancer. Seven months after surgery she visited again, due to ocular pain that started 1 week earlier in the left eye, as well as a headache, and was diagnosed with posterior scleritis upon fundus examination, ultrasonography and MRI. Methylprednisolone was administered orally and an effective treatment result was obtained. After discharge, the patient was followed up for 5 months and did not show any signs of recurrence. Conclusions: When a hyperthyroidism patient has ocular pain or a headache, the possibility of posterior scleritis accompaniment should be considered, as well as the possibility that posterior scleritis, which already occurred in one eye, mayrecur in the other eye.

Recurrent Nodular Scleritis Preceding an Adult TINU Syndrome

Purpose: To describe the occurrence of nodular scleritis in a patient developing tubulointerstitial nephritis and uveitis (TINU) syndrome. Design: Observational case report. Method: The case notes of a 57-year-old female presenting with recurrent nodular scleritis, who later developed interstitial nephritis with bilateral uveitis, were reviewed. Results: Common and established causes of scleritis were not present in an adult who developed the TINU syndrome a decade later. Conclusions: Although scleritis has not been reported as a tubulointerstitial nephritis-associated ocular inflammation, it may be part of the possible spectrum of ocular inflammation occurring as part of the TINU syndrome.

Recurrent Posterior Scleritis—Report of a Case

Posterior scleritis is a serious ocular inflammatory and potentially blinding disorder. It is uncommon and often under-recognized due to its varied presentations, and general ophthalmologists are not familiar with it. Posterior scleritis may be idiopathic or associated with systemic diseases. Visual disturbances such as blurring or distortion are the commonest symptoms. There may be pain, tenderness, and deep-seated discomfort in and around the orbit. One study reported a 49% recurrence rate of posterior scleritis. Posterior scleritis responds well to systemic nonsteroidal anti-inflammatory agents, systemic steroids, and immunosuppressive agents. Recurrences are known to occur despite therapy. However, multiple recurrences in posterior scleritis are uncommon. We report a patient with posterior scleritis who had one episode in the right eye and four episodes in the left eye over a 35-month period.

ORIGINAL ARTICLE, Deep Intramuscular Methylprednisolone Treatment of Recurrent Scleritis

Purpose: To evaluate the efficacy of deep intramuscular methylprednisolone (IMMP) in the treatment of recurrent scleritis. Methods: A total of 15 patients with scleritis (12 anterior, 3 pan) underwent IMMP injection deep into the thigh. Thirteen patients were already being treated with oral non-steroidal anti-inflammatory drugs, oral prednisolone, an oral immunosuppressive agent, or a combination of these drugs. A second IMMP injection was given to nine patients, making a total of 24 injections. Follow-up ranged from 4 to 18 months. Results: There was a documented improvement in scleritis after 21/24 (87.3%) injections with a mean duration of improvement of 5.7 months. No patient required the introduction of oral corticosteroid or immunosuppressive agent, and only one patient required an increase in methotrexate to control the disease. No systemic, injection site, or ocular side effects were noted. Conclusions: Deep IMMP is a safe and effective treatment for scleritis. It ensures compliance, avoids the systemic side effects of oral corticosteroids, and is easily repeatable in the outpatient setting.

Mycophenolate mofetil for the treatment of scleritis

Purpose To evaluate the usefulness of mycophenolate mofetil (MMF) (CellCept, Roche, Nutley, NJ), an antimetabolite immunosuppressant with a selective antiproliferative effect on T and B lymphocytes, for the treatment of scleritis. Design Retrospective, noncomparative case series. Participants Eight patients with scleritis treated with MMF in a tertiary referral center. Methods Review of the clinical records of patients evaluated at the National Eye Institute and prescribed MMF for the treatment of scleritis. Main outcome measures Control of scleral inflammation, the ability to taper prednisone or other immunosuppressive medications, and adverse events were recorded for each patient. Mycophenolate mofetil was determined to be an effective steroid-sparing agent if the daily prednisone dosage could be reduced by 50% or more and was determined to be an effective adjunctive immunosuppressive agent if the scleral inflammation was controlled in patients with active scleritis. Results Four patients with diffuse anterior scleritis, two with necrotizing scleritis with inflammation, one with nodular anterior scleritis, and one with nodular anterior and posterior scleritis, were identified. Mycophenolate mofetil administration was initiated as a steroid-sparing agent in 4 patients with controlled scleritis and as an additional immunosuppressive agent in 4 patients with active scleritis receiving concomitant treatment with prednisone and cyclosporine or methotrexate. In 3 of the 4 patients started on MMF as a steroid-sparing agent, the scleritis remained controlled while the prednisone dosage was tapered by more than 50%. One of the patients started on MMF as a steroid-sparing agent had recurrent scleritis, and each of the patients with active scleritis continued to have persistent scleral inflammation requiring additional immunosuppressive therapy. Adverse effects recorded in 4 of the 8 patients included a rash, gastrointestinal symptoms, paresthesias, and laboratory evidence of hepatotoxicity and renal toxicity. Conclusions Although MMF maybe be useful as a steroid-sparing agent, it was not effective as an adjunctive immunosuppressive agent in patients with active scleritis in our small, tertiary referral series. The adverse effects encountered with the use of MMF in this study cannot be attributed conclusively to MMF and are more likely complications of the multiagent systemic immunosuppressive therapy required for the treatment of recalcitrant scleritis.

Recurrent scleritis in lepromatous leprosy

Abstract Background: Recurrent immune‐mediated scleritis after adequate treatment of leprosy is not well documented in the literature. We describe an Australian resident with unilateral intra‐ocular lepromatous leprosy who had persistent non‐infectious scleritis. Methods: A man of Anglo‐Indian ancestry initially presented with lepromatous leprosy and unilateral ocular involvement. The affected eye had an interstitial keratitis and a granulomatous anterior uveitis that responded to antileprotics and anti‐inflammatory agents. Despite systemic cure with triple antileprotic therapy, he developed recurrent scleritis that required multiple scleral patch grafts for scleral thinning and, subsequently, an enucleation. Histology failed to demonstrate persistent infection, rather a chronic non‐granulomatous scleritis, which was probably immune mediated. Results/Conclusions: This case demonstrates an ocular complication of leprosy that is infrequently reported. Patients with ocular involvement by leprosy are at risk of developing recurrent scleritis despite systemic cure with antileprotics.

Therapy of Nonnecrotizing Anterior Scleritis with Subconjunctival Corticosteroid Injection

To determine the safety and efficacy of subconjunctival triamcinolone (Kenalog) in treating nonnecrotizing anterior scleritis. The authors conducted a retrospective review of all patients treated with depot subconjunctival corticosteroid injection for scleritis from January 1988 to May 1993. Response to therapy was determined by subjective improvement in pain and a decrease in clinical signs of ocular inflammation. All patients received subconjunctival injections of triamcinolone by the same technique, and the minimum observation period for complications was 6 weeks. Eighteen patients (90%) had relief of their symptoms with clinically observable improvement in inflammation, whereas two patients (10%) responded poorly. Nine patients (45%) required no further therapy. Average symptom-free interval was 18 weeks in patients with recurrent scleritis. No complications of scleral thinning, perforation, or glaucoma occurred in any patients. Subconjunctival triamcinolone injection is highly efficacious in treating nonnecrotizing anterior scleritis without unreasonable risk of thinning and/or perforation and should be considered as adjunctive therapy in localized disease.

Recurrent scleritis with elevation of the retina: case report.

Intermittent elevation and settling of the retina in a patient with recurrent scleritis was observed and considered an unusual feature in this not uncommon clinical entity. The marked localized increase in thickness of the sclera was thought also to be of interest. Report of Case A 52-year-old white woman first visited the Eye Clinic on July 25, 1955, with the complaint of pain in the left eye for six to seven weeks' duration. A complete ophthalmic examination revealed only superficial injection of the bulbar conjunctiva in the region of the medial canthus and a refractive error in the affected eye (left). The patient's vision was as follows: The correction for the left eye was -0.75[unk] -1.75 ax 105. The ocular tension was right eye 14 mm. Hg (5.5) Schiotz and left eye 10 mm. Hg (5.5) Schiotz. The conjunctival injection cleared and the patient became asymptomatic in one week while