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S. Schwartzman, T. Flynn, C.M. Samson; The Effects of Biological Anti–TNF Agents in Patients With Scleritis . Invest. Ophthalmol. Vis. Sci. 2006;47(13):590.
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Define response to anti–TNF agents in patients with resistant scleritis.
Resistant scleritis, can occur as a manifestation of an underlying systemic autoimmune illness or it can present as an idiopathic condition. It can be a vision threatening entity and as importantly, it generally portends a poor prognosis for an associated systemic disease when this is present. To date there are no publications on the use of Anti–TNF agents in patients with Scleritis.
Retrospective review of cases identified as having received anti–TNF agents for the treatment of resistant scleritis. Comprehensive chart review of an academic rheumatic disease practice and the practices of 2 ophthalmologists who have limited their practices to autoimmune ophthalmic diseases. Evaluation included the following variables: Underlying ophthalmic disease and systemic autoimmune illness, duration of illness, previous therapies, current therapy, toxicities, dose and duration of biologic treatment. Outcome measures included: decrease in steroid and DMARD use, ultrasound (when available) and pain.
Three patients were identified who received anti TNF therapy for resistant scleritis. One patient with juvenile arthritis and scleritis developed a "lupus like" reaction after infliximab and was switched to adalimumab. When compliant with the medication, scleritis was controlled, however when non–compliant disease flared. This patient still requires adalimumab, cyclosporine and prednisone 20 to 30 mg. In the 2 patients taking infliximab, infliximab was given at a dose of 5 mg/kg in one patient and 10mg/kg in the other patient every 4 weeks. Duration of therapy with infliximab is ongoing in the first patient and she has been treated for 37 months with this medication. She is also on mycophenolate. In the second patient due to complete ultrasound proven resolution, infliximab therapy has been discontinued after 11 months. Cyclosporine has been maintained and mycophenolate and corticosteroids have been discontinued. All three patients were on the equivalent of 40 to 60 mg of prednisone at the initiation of therapy with anti– TNF agents.
In this small series, there seemed to be some validity to support the use of anti –TNF agents in patients with resistant scleritis. One significant side effect observed was a "lupus like" illness. Clearly larger studies are needed to further define the utility of these agents in scleritis.
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