Treatment of Inflammatory Scleritis

Diagnostic Priorities

Urgent ophthalmology consultation is required for patients with muddy or discolored appearance of the sclera, suggesting scleritis, to confirm diagnosis and classify the subtype (diffuse anterior, nodular anterior, necrotizing, or posterior scleritis) 1

The American College of Rheumatology recommends starting with oral NSAIDs as initial therapy for non-necrotizing anterior scleritis, and adding oral corticosteroids if NSAIDs fail after 1-2 weeks or if disease is moderate-to-severe at presentation, with a tapering schedule over 6-8 weeks based on clinical response 1
For necrotizing scleritis or refractory cases, immediate systemic corticosteroids plus disease-modifying anti-rheumatic drugs (DMARDs) are required, with high-dose oral prednisone (1 mg/kg/day) or IV methylprednisolone for severe cases, and concurrent initiation of steroid-sparing immunomodulatory therapy such as methotrexate, mycophenolate mofetil, or azathioprine 1

Anti-TNF agents, such as infliximab or adalimumab, are recommended when conventional DMARDs fail or for severe necrotizing scleritis, with a treatment schedule of 5 mg/kg IV at weeks 0, 2, 6, then every 8 weeks for infliximab, and 40 mg subcutaneously every 2 weeks for adalimumab 1

Close coordination between ophthalmology and rheumatology/internal medicine is mandatory, with regular ophthalmologic follow-up every 1-2 weeks during acute phase, then monthly during maintenance therapy, to monitor for ocular complications and adjust treatment accordingly 1

Surgically‑induced necrotizing scleritis occurs in approximately 1 in 4,000 ocular surgeries (e.g., strabismus procedures), is more common in adults, and typically presents with progressive scleral thinning and gray‑discolored sclera. 2

A history of ocular surgeries—including strabismus, glaucoma, or other intra‑ocular procedures—increases the risk of developing surgically‑induced necrotizing scleritis. 2

Post‑surgical or post‑traumatic scleral thinning can reveal the underlying uveal tissue, producing a gray or dark patch where the choroid shows through the attenuated sclera. 2