|Year : 2020 | Volume
| Issue : 9 | Page : 1983-1985
Commentary: Rituximab in scleritis
Parthopratim Dutta Majumder
Department of Uvea, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India
|Date of Web Publication||20-Aug-2020|
Dr. Parthopratim Dutta Majumder
Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Sankara Nethralaya, Chennai - 600 006, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dutta Majumder P. Commentary: Rituximab in scleritis. Indian J Ophthalmol 2020;68:1983-5
Over the last few years, there has been an increasing number of reports on the scleritis refractory to standardized therapy. Scleritis can be associated with an underlying systemic disease in up to 50% of patients, with the most common being rheumatoid arthritis (RA) and granulomatosis with polyangiitis (GPA). Management of treatment-resistant scleritis and/or associated systemic disease remains a major challenge. Biological agents have emerged out as a useful alternative in such a scenario. In this current issue of the journal, Murthy et al. highlighted the role of rituximab in managing a case of necrotizing scleritis in a patient with GPA.
Rituximab is a chimeric monoclonal immunoglobulin G (IgG) antibody against CD-20, a B cell surface antigen. It has been used successfully in treating various autoimmune diseases, including RA, systemic lupus erythematosus, and GPA. The drug has shown promising results in the treatment of various ocular inflammatory disorders and intraocular lymphoma in recent years. Rituximab has been shown to be efficacious for the management of scleritis by various case reports, a few small case series, and a randomized trial [Table 1].
GPA is an antineutrophil cytoplasmic antibody (ANCA)-associated small-vessel, necrotizing granulomatous vasculitis. Ophthalmic involvement in GPA can occur up to 45% of the patients and can be presenting manifestation of the systemic disease in 16% of the patients. Ophthalmic involvement in GPA includes episcleritis, scleritis, peripheral ulcerative keratitis, uveitis, retinal vasculitis, and orbital inflammation. Scleritis is considered as one of the most common ocular presentations of GPA, and GPA remains the second most common cause of scleritis after RA. Rituximab was reported to be as efficacious and even superior to cyclophosphamide in the management of ocular GPA., The response to the treatment with rituximab may show variable responses, especially in cases with granulomatous manifestations of ANCA-associated vasculitis (such as orbital inflammation) and may take relatively longer time to remission in some cases of scleritis., Scleral inflammation in GPA is thought to be mediated by ANCA produced by B cells. Depletion of B lymphocytes by rituximab thus helps in the management of scleritis. However, not only ANCA-associated scleritis, rituximab has been found to be efficacious in the management of scleritis secondary to RA and various other autoimmune disorders also.,,,
Recurrence of scleral inflammation was reported with rituximab, especially in studies with a longer follow-up period.,, The majority of such cases responded to the re-treatment with the same drug.,, Rituximab appeared to be superior in terms of safety and efficacy when compared to cyclophosphamide. Stilling-Vinther and Pedersen  reported a case of posterior scleritis in a 81-year-old man with multiple comorbidities who developed Pneumocystis jirovecii pneumonia following treatment with rituximab and died. There are reports of cystoid macular edema following successful treatment of scleritis with rituximab therapy. Secondary infection was reported in 16% of the patients in a retrospective study, with 8% requiring hospitalization.
Rituximab may be considered as the second-line agents for noninfectious scleritis refractory to conventional immunosuppressive therapy. Further prospective controlled long-term studies may help us to confirm and expand our insight on the use of the drug in patients with scleritis.
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