How is scleritis treated?
Systemic therapy is required for scleritis whether it is isolated or in the setting of systemic disease, and pain is often the best indicator of inflammation control. The selection of therapy is based on the subtype of disease and presence of associated systemic features. Oral NSAIDs are generally used as first-line therapy for non-necrotizing anterior scleritis and may be occasionally effective for idiopathic posterior scleritis. If inflammation is not controlled, or in necrotizing scleritis and most cases of posterior scleritis, systemic corticosteroids should be used. Subconjunctival corticosteroid injections may be useful for non-necrotizing scleritis but should be considered with caution due to the risk of scleral melting and globe perforation; as such, corticosteroid injections should likely be avoided in necrotizing forms of disease.
In cases unresponsive to oral corticosteroids, or when the dose cannot be tapered to an acceptable level, steroid-sparing immunosuppressive agents such as methotrexate, azathioprine, mycophenolate mofetil, cyclosporine, or cyclophosphamide may be required. In one study, such agents were required in 23% of diffuse anterior, 7% of nodular anterior, 70% of necrotizing, and 17% of posterior scleritis cases. There are reports of successful use of antitumor necrosis factor (TNF) therapies and rituximab in this setting as well. In cases associated with an underlying systemic disease, the choice of immunosuppression is commonly tailored to agents known to be effective for the systemic illness.
