Scleritis

What is Scleritis?

Scleritis is inflammation of the sclera, the tough white outer wall of the eye, and it is a painful condition that can destroy eye tissue.^[1] Most cases are immune-mediated, and at least half are linked to a systemic immune-mediated disease. A smaller number are caused by infection.^[1]

Common symptoms

The hallmark of scleritis is severe eye pain, often with redness.^{[1, 2]}

• Deep, aching eye pain, sometimes spreading to the face, jaw or head, and often worse at night
• Redness of the white of the eye, which can look purple
• Tenderness when the eye is touched
• Tearing, light sensitivity and blurred or reduced vision

Scleritis is divided into types, including diffuse anterior, nodular anterior, necrotizing and posterior scleritis.^[2] Necrotizing scleritis is the most destructive and vision-threatening form.^[3]

Causes and risk factors

Scleritis can occur in the context of systemic autoimmune and infectious conditions.^[2] Rheumatoid arthritis and granulomatosis with polyangiitis are the most common identifiable systemic diseases linked with necrotizing scleritis, and other associated conditions include lupus and inflammatory bowel disease.^{[2, 3]} Infection after eye surgery or injury is another cause.^[3]

How it is diagnosed and treated conventionally

Diagnosis rests on a careful history, a detailed eye examination by an ophthalmologist, and tests for an underlying systemic disease or infection.^{[1, 4]} Telling infectious from non-infectious scleritis matters, because delay can cause permanent damage, and steroids given for presumed immune scleritis can worsen an infection.^[1] We do not diagnose or manage scleritis.

Initial treatment for non-infectious scleritis is typically an oral NSAID. Local or systemic steroids and immune-modifying drugs, including antimetabolites, calcineurin inhibitors and biologics, are used when needed, and any underlying disease is also treated.^{[2, 4]} Necrotizing disease requires aggressive combination immunosuppression, and infectious scleritis needs long-term antimicrobial therapy and sometimes surgery.^[3]

Why Scleritis calls for a whole-person approach

Scleritis is often part of a body-wide immune condition, not only an eye problem. For this reason, treatment looks beyond the eye to the underlying disease.^[2]

The eye doctor and the rheumatologist lead this work. Supportive care can address some of the burdens around it, such as pain-related stress and poor sleep.

Underlying systemic disease

At least half of cases are associated with a systemic immune-mediated disease, so the rest of the body needs evaluation.^[1] It is important to address the underlying condition.^[2]

Pain and its effects

Severe pain is the defining symptom, and it can disturb sleep and mood. Medical treatment of the inflammation is what addresses the pain from scleritis, and supportive therapies do not replace that.

Treatment side effects

Long-term steroids and immunosuppressants are often needed, and they carry their own burdens that your physicians monitor. Tell any practitioner about every medicine you take.

Acupuncture as supportive care in Scleritis

What the research shows

We found no clinical trials of acupuncture for scleritis. In an interview study of 89 patients at an inflammatory eye disease clinic, 9 had used acupuncture, among other complementary therapies.^[5]

Evidence exists for general symptoms, not for scleritis. An individual patient data meta-analysis of 39 trials with 20,827 people found acupuncture reduced chronic musculoskeletal pain, osteoarthritis pain, headache and shoulder pain more than sham or no acupuncture.^[6] This does not show that acupuncture relieves eye pain. A review of 24 trials in insomnia, whose meta-analysis of 15 trials compared acupuncture with medication, found better sleep scores with acupuncture, though results varied a great deal between studies.^[7]

How acupuncture may work

No studies explain how acupuncture might act in scleritis. In chronic pain, a large meta-analysis concluded that acupuncture's effects cannot be explained by placebo alone, but its mechanisms in eye inflammation are unknown.^[6]

What treatment involves

Treatment uses fine, sterile, single-use needles at points on the hands, arms, legs and body, usually left in place for about 20 to 40 minutes. Needling around an inflamed eye is not appropriate. Sessions would focus on general relaxation, sleep and stress.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as soreness or bruising at a needle site, and serious events occurred in about 1 in 10,000 patients.^[8] Tell the practitioner first if you have a bleeding disorder, take blood thinners, steroids or immunosuppressants, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine as supportive care in Scleritis

The Ayurvedic view

Ayurveda describes inflammation of the white of the eye under traditional categories of eye disease, and links eye inflammation with Pitta, the principle associated with heat. This is a traditional framework, not a biomedical diagnosis.

Therapies that may be used

Care is individualized and gentle, and may include:

• Diet and daily routine aimed at cooling, regular meals and steady sleep
• Stress-reduction practices such as breathing exercises and meditation
• Herbs selected by a practitioner after review of your medicines and from tested sources, since some Ayurvedic products contain heavy metals^[9]

Eye procedures such as cleansing or medicated drops applied to the eye are not appropriate in scleritis, because the eye is inflamed and could be infected. Panchakarma is not appropriate during pregnancy, acute illness or frailty, and scleritis is an acute, serious illness. It should not be used while the eye is inflamed.

What the research shows

There are no clinical trials of Ayurvedic treatment for scleritis. A PubMed search found none. Turmeric (curcumin) has been reviewed for eye conditions, including chronic anterior uveitis, but the reviews describe laboratory and animal models and note that curcumin is poorly absorbed.^{[10, 11]} It is not shown to help scleritis.

Herbal medicine as supportive care in Scleritis

Herbs and formulas that have been studied

No herbal formula has been studied in scleritis. Curcumin is the herb most often discussed for inflammatory eye disease, and reviews describe its effects on inflammatory signaling molecules such as TNF-alpha and IL-6 in autoimmune disease models.^[11] In the survey of inflammatory eye disease patients, 10 of 89 had used herbal medicines.^[5]

What the research shows

There is no clinical evidence for herbal medicine in scleritis. A review of curcumin in autoimmune disease reports benefit in models and notes that human use of purified compounds at higher doses needs extreme caution, with a precise understanding of safe regimens still lacking.^[11] Because scleritis can threaten sight, an unproven herb should never be used in place of, or delay, medical treatment.

Safety and herb-drug interactions

Herbs can interact with medicines, and researchers advise that eye doctors ask patients about complementary therapies because they may interact with immunosuppressive treatment.^[5] A review of herb-drug interactions describes St John's wort lowering ciclosporin and tacrolimus levels, with organ rejection in some cases, and ginkgo causing bleeding with warfarin or aspirin.^[12] Case reports link combining warfarin with herbs including dang gui, dan shen, ginger, ginseng and Boswellia to bleeding and other serious effects.^[13]

Herbal and dietary supplements account for about 20% of drug-induced liver injury in the United States, a concern for people taking methotrexate or other drugs that stress the liver.^[14] Herbs should be prescribed individually and come from tested sources. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes red, painful eyes as liver heat or fire rising, and Ayurveda describes a similar picture as Pitta excess. Researchers working with these ideas study inflammatory signaling and immune cell activity, such as the TNF-alpha and IL-6 pathways in curcumin research.^[11]

No study has shown that a traditional pattern corresponds to the immune processes of scleritis. These frameworks help organize general care, such as calming stress, and they are not a reason to delay eye treatment.

How this care fits with your medical care

Scleritis needs prompt care from an ophthalmologist, often with a rheumatologist treating any underlying disease. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. Our role is limited to general supportive care, such as stress and sleep, after your eye is under medical management.

Do not stop or change prescribed eye drops, steroids or immunosuppressants without your prescriber. Please bring your diagnosis, your ophthalmologist's and rheumatologist's notes, and a full list of medicines and supplements.

When to seek urgent medical care

Scleritis can threaten vision, and new eye symptoms need same-day medical assessment.^{[1, 3]}

• Severe or worsening eye pain, especially pain that wakes you at night
• A red or purple eye with tenderness
• Any drop in vision, blurred vision, or new floaters or flashes
• Increasing light sensitivity
• Eye pain with discharge, fever, or a recent eye injury or surgery
• Any thinning, bulge or change in color of the white of the eye

If you have these symptoms, see an eye doctor or go to the nearest emergency department the same day. For severe symptoms or sudden vision loss, call 911.