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GLASGOW, SCOTLAND — Treatment with a biologic agent may be life- and sight-saving in cases of refractory necrotizing scleritis, as was the case for a 60-year-old man with a 10-year history of rheumatoid arthritis and a 2-week history of red, painful eyes and blurred vision.
The usual treatment involves systemic corticosteroids and immunosuppressants. Cyclophosphamide is the immunosuppressive drug of choice, Dr. Ismael Atchia explained in a poster session at the annual meeting of the British Society for Rheumatology.
The patient in question had joint stiffness and swelling, vasculitic lesions on the fingers, and the articular deformities typical of chronic RA, according to Dr. Atchia of the rheumatology department, Sunderland (England) Royal Hospital. He appeared cachectic and had several decubitus ulcers. He had been treated with nonsteroidal anti-inflammatory drugs, but had never received any disease-modifying antirheumatic drugs.
Ocular examination revealed intense bilateral inflammation manifesting as fulminating, necrotizing scleritis with severe bilateral peripheral ulcerative keratitis that threatened corneal perforation. Laboratory investigations revealed elevated inflammatory markers, with an erythrocyte sedimentation rate of 139 mm/hr, a C-reactive protein measurement of 149 mg/L, and a positive rheumatoid factor titer of 1:640.
Treatment of the ocular symptoms consisted of intensive topical lubrication with carmellose as well as prophylactic chloramphenicol and autologous serum eyedrops. He also received temporary punctual plugs and underwent bilateral temporary lateral tarsorrhaphies.
Systemic therapy included pulses of intravenous methylprednisolone plus oral prednisone (60 mg/day) along with cyclophosphamide (15 mg/kg) with mesna coverage on three occasions during the ensuing 6 weeks, Dr. Atchia noted. The vasculitic skin lesions cleared with the immunosuppressive treatment, but ocular deterioration continued until the right eye perforated at the temporal limbus.
The patient then received intravenous infliximab (3 mg/kg), plus oral methotrexate (10 mg weekly) and continued treatment with oral prednisone. Additional doses of infliximab were given at weeks 2 and 6.
Within 2 weeks of the first infliximab dose, the patient's eyes improved dramatically, according to Dr. Atchia.
“This case suggests that biologic agents may be considered in refractory cases of sight- and life-threatening scleritis. However, these agents are expensive and have potentially serious side effects, so their long-term efficacy and safety for use in inflammatory eye disease remain to be determined,” he concluded.
GLASGOW, SCOTLAND — Treatment with a biologic agent may be life- and sight-saving in cases of refractory necrotizing scleritis, as was the case for a 60-year-old man with a 10-year history of rheumatoid arthritis and a 2-week history of red, painful eyes and blurred vision.
The usual treatment involves systemic corticosteroids and immunosuppressants. Cyclophosphamide is the immunosuppressive drug of choice, Dr. Ismael Atchia explained in a poster session at the annual meeting of the British Society for Rheumatology.
The patient in question had joint stiffness and swelling, vasculitic lesions on the fingers, and the articular deformities typical of chronic RA, according to Dr. Atchia of the rheumatology department, Sunderland (England) Royal Hospital. He appeared cachectic and had several decubitus ulcers. He had been treated with nonsteroidal anti-inflammatory drugs, but had never received any disease-modifying antirheumatic drugs.
Ocular examination revealed intense bilateral inflammation manifesting as fulminating, necrotizing scleritis with severe bilateral peripheral ulcerative keratitis that threatened corneal perforation. Laboratory investigations revealed elevated inflammatory markers, with an erythrocyte sedimentation rate of 139 mm/hr, a C-reactive protein measurement of 149 mg/L, and a positive rheumatoid factor titer of 1:640.
Treatment of the ocular symptoms consisted of intensive topical lubrication with carmellose as well as prophylactic chloramphenicol and autologous serum eyedrops. He also received temporary punctual plugs and underwent bilateral temporary lateral tarsorrhaphies.
Systemic therapy included pulses of intravenous methylprednisolone plus oral prednisone (60 mg/day) along with cyclophosphamide (15 mg/kg) with mesna coverage on three occasions during the ensuing 6 weeks, Dr. Atchia noted. The vasculitic skin lesions cleared with the immunosuppressive treatment, but ocular deterioration continued until the right eye perforated at the temporal limbus.
The patient then received intravenous infliximab (3 mg/kg), plus oral methotrexate (10 mg weekly) and continued treatment with oral prednisone. Additional doses of infliximab were given at weeks 2 and 6.
Within 2 weeks of the first infliximab dose, the patient's eyes improved dramatically, according to Dr. Atchia.
“This case suggests that biologic agents may be considered in refractory cases of sight- and life-threatening scleritis. However, these agents are expensive and have potentially serious side effects, so their long-term efficacy and safety for use in inflammatory eye disease remain to be determined,” he concluded.
GLASGOW, SCOTLAND — Treatment with a biologic agent may be life- and sight-saving in cases of refractory necrotizing scleritis, as was the case for a 60-year-old man with a 10-year history of rheumatoid arthritis and a 2-week history of red, painful eyes and blurred vision.
The usual treatment involves systemic corticosteroids and immunosuppressants. Cyclophosphamide is the immunosuppressive drug of choice, Dr. Ismael Atchia explained in a poster session at the annual meeting of the British Society for Rheumatology.
The patient in question had joint stiffness and swelling, vasculitic lesions on the fingers, and the articular deformities typical of chronic RA, according to Dr. Atchia of the rheumatology department, Sunderland (England) Royal Hospital. He appeared cachectic and had several decubitus ulcers. He had been treated with nonsteroidal anti-inflammatory drugs, but had never received any disease-modifying antirheumatic drugs.
Ocular examination revealed intense bilateral inflammation manifesting as fulminating, necrotizing scleritis with severe bilateral peripheral ulcerative keratitis that threatened corneal perforation. Laboratory investigations revealed elevated inflammatory markers, with an erythrocyte sedimentation rate of 139 mm/hr, a C-reactive protein measurement of 149 mg/L, and a positive rheumatoid factor titer of 1:640.
Treatment of the ocular symptoms consisted of intensive topical lubrication with carmellose as well as prophylactic chloramphenicol and autologous serum eyedrops. He also received temporary punctual plugs and underwent bilateral temporary lateral tarsorrhaphies.
Systemic therapy included pulses of intravenous methylprednisolone plus oral prednisone (60 mg/day) along with cyclophosphamide (15 mg/kg) with mesna coverage on three occasions during the ensuing 6 weeks, Dr. Atchia noted. The vasculitic skin lesions cleared with the immunosuppressive treatment, but ocular deterioration continued until the right eye perforated at the temporal limbus.
The patient then received intravenous infliximab (3 mg/kg), plus oral methotrexate (10 mg weekly) and continued treatment with oral prednisone. Additional doses of infliximab were given at weeks 2 and 6.
Within 2 weeks of the first infliximab dose, the patient's eyes improved dramatically, according to Dr. Atchia.
“This case suggests that biologic agents may be considered in refractory cases of sight- and life-threatening scleritis. However, these agents are expensive and have potentially serious side effects, so their long-term efficacy and safety for use in inflammatory eye disease remain to be determined,” he concluded.