Posterior or Necrotizing Scleritis: Next Step After Corticosteroid Failure
Posterior and necrotizing scleritis are the most severe and urgent presentations of scleral inflammation. When high-dose systemic corticosteroids do not achieve sustained disease remission, a structured escalation is indicated.
Clinical Scenario
Patients presenting with posterior or necrotizing scleritis require significantly more intensive and urgent therapy than those with anterior non-necrotizing disease. High-dose systemic corticosteroids — oral or intravenous — are the established first approach to induce remission in this population.
Why Escalation Is Triggered
This protocol applies when high-dose systemic corticosteroids (oral or intravenous) have not achieved the primary target: disease remission with sustained control of scleral inflammation. Persistent or relapsing inflammation despite corticosteroid therapy is the clinical signal to move to the next step.
The Next Therapeutic Step
At this stage, adjunctive second-line immunosuppressive therapy is introduced. Several immunomodulatory agent classes are considered within this step — the specific selection, criteria, and sequencing are detailed in the full protocol.
The clinical goal is control of scleral inflammation, to relieve pain and preserve ocular integrity.
References
DOI: 10.1016/j.survophthal.2005.04.001
- Patients with posterior or necrotizing scleritis need much more intensive and urgent therapy than those presenting with anterior non-necrotizing disease.
- Corticosteroids are usually reserved for patients who do not respond to cox-inhibitors or those with posterior or necrotizing disease.
- Patients who relapse at doses of prednisolone >7.5–10 mg per day should be considered for adjunctive immunosuppressive therapy with a second-line agent that includes cyclosporin, mycophenolate, methotrexate, and anti-TNF blockers.
- The aim of treatment is to remove or treat the cause where possible but in the majority is to control the inflammatory process to relieve the pain and thereby reduce the damage to the eye.