We kindly thank Drs Serna-Ojeda and Flores-Suárez for their interest in our recent article, entitled “Rituximab in the Treatment of Refractory Noninfectious Scleritis.” We are encouraged by the positive response of their additional 8 patients to a similar therapy.
Here at the Massachusetts Eye Research and Surgery Institution, it is our practice to titrate immunosuppressive therapy so as to achieve steroid-free durable remission. The long-term ocular and systemic effects of even low-dose glucocorticoid exposure have been well documented. Furthermore, the treatment aim is to achieve durable free remission and even possibly cure; we cannot appropriately assess for true immune quiescence if corticosteroids on board are masking low-grade inflammation, fooling us into believing that no further immunomodulation is required.
This is more clearly demonstrated by contrasting our case series with the only randomized controlled study by Suhler and associates. In both studies, nearly all patients initially showed a favorable response to rituximab. However, on long-term follow-up, nearly all patients in Suhler’s trial eventually relapsed. Our study differed from Suhler’s study in that our treatment endpoint was not clinical remission with permissive use of corticosteroids, but rather clinical remission in the absence of concomitant steroid use. Importantly, in our case series, 86.6% of patients were able to achieve drug-induced, steroid-free remission with rituximab ± additional agents, and 2 patients achieved durable drug-free remission with a follow-up of greater than 3 years’ duration each at the time of submission of this letter.
While there are few studies that use the McCluskey activity scale, we found it to be helpful in providing an objective (vs binary) recording of disease activity. This was particularly helpful as, unlike other studies, our primary endpoint was not percent reduction in corticosteroid dependence, but clinical disease remission in the absence of steroids. Furthermore, one of the only prospective clinical trials on the use of rituximab in refractory scleritis published by Suhler’s group also uses this scale. We would be happy to reanalyze our data using an alternatively proposed grading scale, but are confident that a statistically significant benefit in response of recalcitrant scleritis to rituximab therapy will hold.
We acknowledge that rituximab is an expensive medication with potential life-threatening side effects and that serial treatments may be required as chronic treatment. However, the safe use of rituximab has been established in the treatment of several autoimmune diseases. We further counter the “cost of treatment using rituximab” argument with the counter-costs of treatment and morbidity of long-term side effects of glucocorticoid steroid use, as well as the cost of blindness with regard to quality of life and individual lifetime productivity from complications of scleritis and/or the ocular complications of corticosteroid use.
We agree that the medical evidence for the safe and successful use of rituximab in scleritis is nascent and further studies are needed to further elucidate the role of rituximab and ideal dosing schedules in the treatment of scleritis. However, we continued to be encouraged by our success with this medication.