[Severe bilateral pseudomonas sclerokeratitis in comatose patient (clinical case)]. / Razvitoi dvustoronnii sinegnoinyi sklerokeratit u patsientki v kome (klinicheskii sluchai).

The article presents a clinical case of severe bilateral pseudomonas sclerokeratitis in a patient with occlusion hydrocephalus and intracranial hypertension, who was in a coma and on a ventilator for 20 days. At first examination (7 days after the onset of purulent keratitis, during which the process had been rapidly progressing), the clinical picture included lagophthalmos, severe purulent corneal ulcer, bilateral purulent scleromalacia, perforated cornea in the left eye. On the same day, in order to maintain eye integrity, urgent reconstructive penetrating sclerokeratoplasty with subsequent sclerocorneal coating was performed in both eyes right in the intensive care unit. Parts of the melted iris and ciliary body pars plana that were left in place were abundantly washed with BSS and moxifloxacin solutions - 150 µg/ml. Postoperative care included forced instillations of antibiotics and antiseptics. Two years after the first surgery, 2 more full-thickness corneal transplantations were performed in the patient's right eye aiming at restoration of its optical system. Thus, immediate sclerokeratoplasty with anterior segment irrigation and intraocular administration of highly diluted antibiotics appeared to be the only chance to save the vision in one eye. The fellow eye, where perforation occurred as a result of severe purulent sclerokeratitis and purulent iridocyclitis, despite all measures taken, lost its sight. After three surgeries (penetrating sclerokeratoplasty and two re-PK), visual acuity in the only seeing (right) eye was 0.1, which can be considered a satisfactory result.

Management of Scleritis in Older Adults.

Scleritis, an inflammatory disease of the eye affecting scleral tissue, presents unique challenges in the older adult population. Unlike their younger counterparts, older individuals manifest a distinct spectrum of the disease with different underlying etiologies, co-morbidities, altered immune function, and an increased risk of systemic side effects from medication choices. Addressing these complexities necessitates a comprehensive and multidisciplinary approach. Treatment of choice will depend on any underlying cause but generally involves non-steroidal anti-inflammatory drugs, systemic or local corticosteroids, and potentially disease-modifying anti-rheumatic drugs. Utilization of these therapeutic agents in older adults warrants careful consideration because of their potential side-effect profiles. This article critically examines the specific concerns for the use of these drugs in older patients and reviews the existing literature on their use in this specific cohort.

Scleritis after proton therapy in uveal melanoma.

BACKGROUND: Sclera is a very radioresistant tissue and scleritis after proton therapy has not been described so far. HISTORY AND SIGNS: Four female patients, aged between 31 and 74 years, were treated with proton therapy for uveal melanoma (height range: 2.2 - 3.5 mm), located in the macula, the superior equator and 2 in the ciliary body. All patients had a history of a previous or active inflammatory disease and developed scleritis after radiotherapy. THERAPY AND OUTCOME: Two patients had infectious scleritis and were treated with adequate antibiotic therapy. After systemic corticotherapy, 3 patients recovered completely; the remaining patient was managed with additional immunosuppressive treatment as well as a conjunctival and scleral graft, but has not become pain free yet. CONCLUSION: Scleritis is a possible complication after proton therapy, probably on an ischemic basis, where there is a predisposing factor such as inflammatory systemic disease.

Infective Necrotizing Scleritis After XEN Gel Stent With Mitomycin-C.

PURPOSE: The purpose of this study was to report a case of infective necrotizing scleritis following XEN Gel Stent with mitomycin-C. METHODS: Case report. This is a case report of a 68-year-old woman. RESULTS: XEN Gel Stent glaucoma surgery enhanced with mitomycin-C 0.04% and combined with cataract surgery was performed at a regional center to manage the patient's primary open-angle glaucoma. Past medical history was significant for rheumatoid arthritis requiring treatment with methotrexate and adalimumab. Periocular pain and swelling developed 14 months after the initial operation, followed by a rapid deterioration of visual acuity to 20/60, intraocular pressure of 4 mm Hg, and worsening pain 5 months later. On initial presentation to Sydney Eye Hospital, 180 degrees of scleral necrosis was evident with a moderate anterior segment inflammatory reaction and a large temporal choroidal effusion due to hypotony. Empirical hourly topical ofloxacin and cephalothin 5% drops, with oral moxifloxacin, were initiated. Conjunctival swab grew Staphylococcus aureus and Staphylococcus lugdunensis. Significant clinical improvement occurred, but the XEN Gel Stent became exposed after 9 days of treatment with worsening hypotony. Urgent surgical revision was performed to remove the XEN Gel Stent and apply a tutoplast plug with overlying amniotic membrane graft. Intraocular pressure gradually improved over 6 weeks to 15 mm Hg with reversal of hypotonous changes, and visual acuity stabilized at 20/40. CONCLUSIONS: To our knowledge, this is the first reported case of necrotizing scleritis following XEN Gel Stent insertion. It is a reminder that infection should always be the primary differential diagnosis in patients with surgical-induced necrotizing scleritis.

[Relapsing polychondritis]. / La polychondrite chronique atrophiante.

Relapsing polychondritis is a rare systemic disease. Clinical manifestations are variable and the condition is frequently associated with other diseases. Chondritis typically involves ears, nose, costal cartilages and upper airways. Other classical features include scleritis and episcleritis, mucocutaneous lesions, arthralgia and constitutional symptoms. Repeated inflammation of cartilaginous structures may lead to deformities of the ears, the nose and the airways. Tracheobronchomalacia and aortitis of the ascending portion resulting in aortic regurgitation or aneurysm are feared complications. Treatment is mainly based on systemic corticosteroids alone or in association with immunosuppressants. Several biological immunosuppressive agents are reported effective in refractory disease.

Infliximab treatment in a case of rheumatoid scleromalacia perforans.

Ocular rheumatoid disease manifests as hyperemia of the conjunctiva and episclera, and in severe cases, episcleritis can result in nodular sclerotic and scleromalacia perforans. A clinical case of scleromalacia perforans in a 56-year-old woman with 20 years of seropositive rheumatoid arthritis of functional class IV is presented here. During that period, she received exclusively non-steroidal anti-inflammatory drugs (NSAIDs). She developed acute episcleritis of the left ocular globe, which rapidly progressed to scleromalacia perforans. Since the left eye became perforated, it was surgically enucleated, and the patient was maintained with steroidal therapy. Nevertheless, two months later she developed new-onset episcleritis of the right eye followed by scleromalacia. She was first evaluated by a rheumatologist and treated with 200 mg/dose of infliximab, which was administered monthly for the following four months. The biological treatment was accompanied by methotrexate and prednisone. With this therapy, the ocular lesion dramatically improved, and complete remission of rheumatoid arthritis and scleritis was archived four months later. In conclusion, tumour necrosis factor (TNF) blockers are effective therapeutic agents in ocular complications of rheumatoid arthritis.

[Scleral necrosis after scleral buckling surgery of the patient with pyoderma gangrenosum]. / Martwica twardówki po operacji wglabiajacej u chorej z pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is a rare skin disease caused by immune dysfunction. The systemic diseases are often associated. The aim of the study was to report necrotic scleritis which developed after scleral buckling procedure in the case of the 64 years old patient suffered from primary retinal detachment and idiopathic PG. The retinal reattachment was achieved. The conjunctival wound dehiscence, necrotising scleritis and marginal keratitis as a manifestation of the patergic reaction were diagnosed. The treatment with corticosteroids locally (Dexamethason) and systematically (Prednison and Sulfasalazine), was administrated. The improvement and stabilisation of the local condition of ocular surface were observed. After reduction of systemic drugs, the exacerbation of local inflammation and vitritis was observed. The prolonged therapy was necessary. The risk of wound healing disturbances of an ocular surface with aggravated necrotic reaction must be expected after ocular surgery of the patient with PG. The adequate immunosupressive prolonged treatment with proper collaboration with the dermatologist is necessary.

Nodular scleritis and Sweet's syndrome.

The authors report a case of nodular scleritis in Sweet's syndrome. The patient was a 40-year-old Malay woman with a history of Sweet's syndrome presented with a 6-day history of a red and painful right eye associated with blurred vision. Clinical examination revealed nodular scleritis of the right eye which was deemed secondary to Sweet's syndrome after investigations for other systemic diseases were negative. The patient demonstrated good response to systemic corticosteroid therapy with complete resolution of scleritis in the right eye. However, her inflammatory skin condition worsened each time the systemic corticosteroids were tapered so colchicine and dapsone were added to treat the dermatologic disease. Ocular manifestations are uncommon in Sweet's syndrome but it is important to diagnose and treat them. This will prevent ocular morbidity and ensure a good clinical outcome.

[Cyclosporin A therapy in severe anterior scleritis. 5 severe courses without verification of associated systemic disease treated with cyclosporin A]. / Ciclosporin-A-Therapie bei schweren anterioren Skleritiden. Fünf schwere Verläufe ohne nachgewiesene assoziierte Systemerkrankung unter systemischer Ciclosporin-A-Therapie.

BACKGROUND: Patients with severe scleritis who do not respond to high-dose corticosteroid therapy, or who require a daily corticosteroid maintenance dose higher than 30 mg prednisone should be treated by other immunosuppressants. PATIENTS AND METHODS: In five patients with various types of severe anterior scleritis a long-term high-dose steroid treatment failed to control scleral inflammation. They therefore received cyclosporin (CsA). Follow-up was 16-26 months. RESULTS: Scleral inflammation and ocular complications were controlled in all patients by a regimen of systemic CsA combined with a low maintenance steroid dose below the Cushing threshold. We observed no side effects under CsA serum levels of 120-150 ng/ml. In only one patient was scleral inflammation totally and lastingly eliminated. CONCLUSIONS: Systemic CsA therapy is of definite therapeutic value in the symptomatic management of steroid refractory severe anterior scleritis without associated systemic disease. Complete healing, however, is achieved only in a minority of cases.

[Rosacea with ocular involvement in a child]. / Rosacée de l'enfant avec atteinte oculaire.

INTRODUCTION: Rosacea ia an uncommon facial eruption in children. We report a case of rosacea associated with a specific episcleritis. CASE REPORT: A 10-year-old girl consulted for an erythematous papular and pustular eruption of the mid face of 1 month duration. The child complained that she had had a red painful right eye for 6 months. There was no argument for acne, periorificial granulomatous dermititis or for sarcoidosis. The ophthalmological examination gave the diagnosis of ocular and cutaneous rosacea. Oral antibiotics followed by erythromycin gave favorable results for both skin and ocular lesions. DISCUSSION: Ocular involvement is a frequent complication of rosacea in adults. It is exceptional in children in whom rosacea is in itself rare. The presence of blepharitis, keratoconjunctivitis or episcleritis may suggest the diagnosis in a child with a mid facial eruption. As in the adult, skin and ocular rosacea responds well to prolonged oral antibiotics. The choice of the antibiotic depends on the age of the child. Cyclins are not authorized in children under the age of 8 years.

Necrotizing scleritis after strabismus surgery in thyroid eye disease.

Surgically induced necrotizing scleritis, which can lead to potentially devastating consequences, is a rare sequela to many types of ocular surgeries. We describe a 58-year-old woman who developed necrotizing scleritis following strabismus surgery for thyroid ophthalmopathy. Tectonic corneal patch grafting resulted in a favorable outcome.

Pharmacotherapy of scleritis: current paradigms and future directions.

INTRODUCTION: Scleritis is an inflammatory condition affecting the eye wall that may be associated with a number of systemic inflammatory diseases. Because scleritis can be refractory to standard treatment, knowledge of the body of available and emerging therapies is paramount and is reviewed here. AREAS COVERED: This review focuses on both traditional and emerging therapies for noninfectious scleritis. The authors cover the mechanisms of action and potential adverse effects of each of the treatment modalities. In addition, a summary of the significant MEDLINE indexed literature under the subject heading 'scleritis', 'treatment', 'immunomodulator' will be provided on each therapy, including commentary on appropriate use and relative contraindications. Novel treatments and potential drug candidates that are currently being evaluated in clinical trials with therapeutic potential will also be reviewed. EXPERT OPINION: While oral nonsteroidal anti-inflammatory drugs and oral corticosteroids are widely used, effective, first-line agents for inflammatory scleritis, refractory cases require antimetabolites, T-cell inhibitors, or biologic response modifiers. In particular, there is emerging evidence for the use of targeted biologic response modifiers, and potentially, for local drug delivery.

Subconjunctival triamcinolone acetonide in the management of ocular inflammatory disease.

PURPOSE: To review the existing evidence that supports the subconjunctival use of triamcinolone acetonide (TA) in the treatment of various ophthalmic diseases. METHODS: A literature search was performed for published articles about the pharmacokinetic (PK) and pharmacodynamic characteristics of triamcinolone, as well as its potential ophthalmic use, focused mainly in the subconjunctival mode of delivery. Search terms included corticosteroids, triamcinolone, ocular, subconjunctival, and ophthalmic. RESULTS: Corticosteroids represent the mainstay of treatment of ocular inflammation, exerting their action by affecting multiple pathways of the inflammatory response, making them particularly effective in the majority of cases. However, due to the number and severity of the side effects associated with their use, they have to be given with caution. Corticosteroids can be given topically, subconjunctivally, intraocularly, and systemically to treat a variety of ocular diseases with specific pharmacological and PK characteristics. Triamcinolone is one of the most widely used corticosteroids in the treatment of ocular inflammation. This glucocorticoid used subconjunctivally was proven to be particularly safe and effective in some common and important inflammatory ophthalmic diseases such as anterior scleritis, uveitis, and corneal graft rejection. Further, there are other indications for its successful use where data exist, but somehow less abundant. CONCLUSIONS: This article highlights the potential of TA to complement the treatment armamentarium of anterior segment inflammation.

Certolizumab pegol therapy for rheumatoid arthritis-associated scleritis.

PURPOSE: To report the successful treatment of rheumatoid arthritis (RA)-associated scleritis with the tumor necrosis factor alpha antagonist certolizumab pegol. METHODS: Retrospective case report of therapeutic interventions for a 47-year-old woman with scleritis and RA. After not tolerating treatment with other tumor necrosis factor alpha inhibitors and rituximab, or after that treatment failed, certolizumab pegol was administered in an attempt to achieve better control of her disease process. RESULTS: Six months after beginning the new therapy, it was well-tolerated and the patient's RA and scleritis were quiescent. CONCLUSIONS: Certolizumab pegol may successfully treat RA-associated scleritis, even in a patient who has not tolerated therapy with other tumor necrosis factor alpha antagonists or in whom that treatment has failed.

Episcleritis and scleritis.

Episcleritis and scleritis are two common inflammatory disorders encountered by primary care practitioners. Although episcleritis is a self-limited disease that usually resolves within 2 to 3 weeks, severe symptoms may require the use of topical steroids or, in recalcitrant cases, nonsteroidal anti-inflammatory agents (NSAIAs). Scleritis is a painful, generalized inflammation of the eye that is often associated with systemic disease. The necrotizing form of scleritis is the most serious, requiring aggressive treatment with NSAIAs and systemic steroids. Significant sequelae of scleritis include uveitis, glaucoma, cataract, and retinal detachment.