About half the time, scleritis occurs in both eyes; recurrences are common, Dr. Askanase says.
Rheumatic Disease & Scleritis
About half of the patients who have scleritis have associated rheumatic disease.
“Scleritis can occur in a number of systemic inflammatory diseases, more often in patients with an established diagnosis who develop ocular symptoms and are diagnosed by an ophthalmologist,” says rheumatologist Christopher Wise, MD, professor, internal medicine, Virginia Commonwealth University, Richmond, Va.
Because RA is the most common form of chronic inflammatory arthritis seen by rheumatologists, that’s also the condition most often associated with scleritis, particularly in patients with severe RA, Dr. Wise says. However, he also believes the number of RA-associated scleritis cases is decreasing due to more effective RA therapies now available.
Other conditions associated with scleritis include inflammatory arthropathies, lupus and related autoimmune diseases, and systemic vasculitis. Sjögren’s syndrome is an underdiagnosed condition that can be associated with scleritis, Dr. Akpek says.
Cases of scleritis associated with previously undiagnosed granulomatosis with polyangiitis (GPA) are important to catch, because GPA can be fatal if not treated, says ophthalmologist John D. Sheppard, MD, president of Virginia Eye Consultants, and professor of ophthalmology, microbiology and molecular biology, Eastern Virginia Medical School, Norfolk, Va.
Treatment of Scleritis
Quick diagnosis and treatment of scleritis is essential to avoid debilitating visual consequences. “Corneal melts and scleral perforations are sight-threatening sequelae of uncontrolled scleritis. The correct and rapid diagnosis and the appropriate systemic therapy can halt the relentless progression of both ocular and systemic processes, preventing destruction of the globe and prolonging survival,” Dr. Lacayo says.
Treatment for scleritis depends on identifying the source of systemic inflammation with bloodwork. Systemic or oral nonsteroidal anti-inflammatory drugs (NSAIDs), systemic steroids and immunosuppressive agents, such as methotrexate, cyclosporine and azathioprine, are part of the treatment combination, Dr. Lacayo says.
Physicians must know if a patient has glaucoma or a previous ocular herpetic infection, as well as renal, gastric, hepatic, hematologic or tuberculous disease, because those conditions can limit the treatment options, Dr. Sheppard says.
If the cause of scleritis is unknown, first-line treatment often is oral NSAIDs; if there is underlying collagen vascular disease, immunosuppression may be required. “In general, controlling the systemic disease results in control of the ocular inflammation,” Dr. Askanase says.
Another scleritis cause that leads to a different treatment course is infection—be it viral, bacterial, fungal or parasitic; Lyme disease should also be considered, Dr. Askanase says. Sometimes, the cause of scleritis cannot be identified.
The Rheumatologist’s Role
In the most common scenario, a patient with scleritis presents to an ophthalmology clinic, not to the rheumatologist; patients with rheumatic disease usually already have their condition diagnosed, Dr. Akpek observed.
