We read with interest the article by Johnson and Chu reporting on the use of sub-Tenon injection of triamcinolone acetonide in the treatment of scleritis. We have been using subconjunctival corticosteroid injection to control acute inflammation in patients with noninfectious nonnecrotizing anterior scleritis. The authors report on the use of triamcinolone acetonide given as sub-Tenon injection as an adjunct to achieve transient, partial improvement of subjective pain and objective inflammation in patients with scleritis while awaiting systemic medications to take effect. In general, the ideal treatment of ocular inflammatory diseases has 3 aims. The first aim is to control acute inflammation. The second is to prevent recurrences of inflammation while under specific therapy. The third is to achieve remission of inflammation after specific therapy has been discontinued. Corticosteroids delivered in any route are and should be used in the control of acute inflammation. They are not expected to control recurrences of inflammation. Hence, the recurrences the authors report after the application of sub-Tenon corticosteroids is the result of the nature of the scleritis, rather than the failure of the corticosteroids to prevent the recurrences. In our routine, we do not use high-dose long-term systemic corticosteroids in the management of ocular inflammatory diseases, including scleritis. It is not clear from the article what was the baseline corticosteroid dose that the authors used for the long-term control of scleral inflammation. We use high-dose corticosteroids only to take rapid control over the inflammation and start the patient on immunosuppressive medications in case there are recurrences of inflammation, preferentially with methotrexate as the initial agent in scleritis. After maintenance of methotrexate therapy is achieved, we ideally discontinue or taper the systemic corticosteroid to a dose of 8 mg methylprednisone or less. In case there is failure with methotrexate, we initially increase the dose of methotrexate. If therapy with methotrexate fails, then we augment immunosuppression following a step-ladder approach moving from low to higher potential agents, biologics, or both.
In addition, it is not clear to us why this method of corticosteroid delivery was used in the 2 cases with Wegener’s granulomatosis (one being suspect). It has to be kept in mind that nonnecrotizing diffuse or nodular scleritis has the potential to progress to necrotizing scleritis, especially in cases with underlying systemic vasculitis. We withheld the use of subconjunctival corticosteroids in cases with or with the potential to develop necrotizing scleritis to avoid any scleral thinning or necrosis from occurring as a potential severe adverse effect of therapy.
In conclusion, subconjunctival corticosteroid injection is a substitute for systemic corticosteroids to take control of scleritis acutely and can be used in the management of acute noninfectious nonnecrotizing anterior scleritis.