Treatment options for necrotizing scleritis in rheumatoid arthritis patients

IntroductionNecrotizing scleritis is more likely to be associated with severe pain, poor visual outcomes, increased mortality, and autoimmune disease such as rheumatoid arthritis. The advent of targeted biologic therapy has revolutionized the treatment of rheumatic diseases, and these medications are currently being explored for ocular inflammatory disease - including necrotizing scleritis, which is often refractory to conventional immunomodulatory therapies.Areas coveredThe authors review available therapies for scleritis, including topical treatments and systemic immunosuppressive agents. Particular attention is given to CD20 inhibitors, TNF alpha inhibitors, IL6 inhibitors, and IL1 inhibitors as they are increasingly used to treat ocular inflammatory disease. Finally, the authors touch on surgical techniques for reinforcing necrotic areas of sclera.Expert opinionThe authors advocate for a standardized clinical grading system of scleritis to facilitate large scale, multicenter, and randomized clinical trials evaluating the efficacy of treatment regimens for noninfectious scleritis - particularly for TNF alpha inhibitors, anti-IL6 agents, and combinations of conventional medications. For noninfectious and recalcitrant necrotizing scleritis, the authors recommend initial therapy with mycophenolate mofetil, followed by a TNF alpha inhibitor or rituximab. As a last resort for severely recalcitrant and/or globe threatening cases, alkylating agents may be necessary.