Another common scenario is a scleritis patient who presents to the ER and receives topical antibiotics, and they show up weeks later to see the ophthalmologist or rheumatologist in dire straits, Dr. Sheppard says.
Ophthalmologists usually are proactive about referring scleritis patients with no diagnosed systemic disease to rheumatologists for evaluation.
Rheumatologists will begin their examination of scleritis patients with a careful history and physical exam, with an emphasis on the musculoskeletal, dermatologic, cardiopulmonary, upper airway, neurologic and renal systems, Dr. Wise says.
Initial lab studies include complete blood count, serum chemistries, inflammatory markers, a chest X-ray and a battery of serologic tests for RA, lupus and related diseases.
“The serologic studies are often helpful if positive, even in patients without obvious clinical features of an underlying disease, [because] scleritis can be the initial manifestation of the condition,” Dr. Wise says.
There is always a need for close collaboration between rheumatologists and ophthalmologists to manage the condition.
First, rheumatologists should keep a close eye on their patients’ eyes, Dr. Lacayo advised. “Scleral tissue should be mostly white in all healthy individuals. Any small amount of scleral injection or recurrent hyperemia should tip the rheumatologist toward stronger or longer treatments with the agents mentioned,” he says.
“In the case that a rheumatologist sees a patient with a red, painful eye, they should send the patient to an ophthalmologist for evaluation,” Dr. Akpek says.
Yet ophthalmologists must stay aware of the need for a referral as well. During therapy, ophthalmologists often consult rheumatologists if a patient’s response to systemic steroid therapy is incomplete or temporary, or if the patient cannot taper steroids without an exacerbation, Dr. Wise says.
“If a patient presents with scleritis associated with joint pain, rash or shortness of breath, fatigue or other systemic complaints, they should be referred to a rheumatologist for evaluation,” Dr. Rubenstein says.
Although there are no new scleritis-specific treatments on the horizon, adalimumab (Humira) is on the cusp of being approved for uveitis, Dr. Sheppard says. This is valuable to know because he finds that uveitis treatments are often effective for scleritis patients. “This condition always takes a back seat to uveitis, but a lot of companies are investigating uveitis to the potential benefit of our scleritis patients as well,” he says.
Vanessa Caceres is a medical writer in Bradenton, Fla.
