Date of Award

January 2021

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Ninani Kombo

Abstract

Scleritis is a highly symptomatic inflammatory disease of the sclera. We conducted a retrospective study to identify demographic factors and comorbidities associated with resolution of scleritis, to compare patient outcomes on different treatments for scleritis, and to compare treatment utilization by the different medical specialties that manage scleritis. The medical records of all patients with a CPT code for scleritis seen at a tertiary care center from January 1, 2013 to January 1, 2020 were reviewed. Data was collected on demographic factors, comorbidities, and treatment. The primary outcome measures were time until resolution of disease, defined as quiescence of inflammation on two or more sequential visits, and time until resolution on steroid-sparing therapy, defined as being on 10 milligrams or less of prednisone without a recurrence of inflammation on two sequential visits. The study was approved by the Yale School of Medicine Institutional Review Board (IRB). We identified in 256 patients (302 eyes) with scleritis, including 232 patients (90.6%) with diffuse anterior scleritis, 10 patients (3.9%) with nodular anterior scleritis, two patients (0.8%) with necrotizing scleritis with inflammation, and three patients (1.2%) necrotizing scleritis without inflammation (scleromalacia perforans). The most commonly used therapies were topical steroids (44.9%), systemic NSAIDs (34%), and systemic steroids (34%). Non-corticosteroid immunomodulatory therapies (IMTs) were required in 39.5% of patients, most commonly methotrexate (17.2%) and TNF-⍺ inhibitors (9.1%). Scleritis was associated with a systemic autoimmune disease in 90 patients (35.2%). These patients were more likely to receive systemic corticosteroids and non-corticosteroid IMTs (p<0.05). Patients with an ophthalmologist involved in their care were more likely to receive acute treatment (p<0.05) and were more likely to receive systemic NSAIDs (p<0.05). Resolution was achieved within 3 months in 45.6% of patients and within 6 months in 57.6% of patients. Steroid sparing resolution was achieved within 3 months in 35.9% of patients and within 6 months in 48.9% of patients. In a Cox proportionate hazards model, NSAID use (p<0.05, OR 2.145, 95% CI [1.200, 3.832]), Hispanic race (p<0.05, OR 2.664, 95% CI [1.036, 6.851]), lupus erythematosus (p<0.005, OR 6.175, 95% CI [1.774, 21.489]), and bilateral scleritis (p<0.05, OR 0.437, 95% CI [0.196, 0.972]) were significantly associated with the resolution of scleritis. TNF-⍺ inhibitors were associated with resolution only at the 90% confidence level (p<0.1, OR 2.210, 90% CI [1.100, 4.440]). TNF-⍺ inhibitors (p<0.05, OR 3.346, 95% [1.277, 8.763]), biologic therapy (including TNF-⍺ inhibitors, when compared against antimetabolites, p<0.01, OR 2.506, 95% CI [1.406, 7.634],) lupus erythematosus (p<0.05), OR 5.251, 95% CI [1.478, 18.659]), African American race (p<0.05, OR 0.467, 95% CI [0.224, 0.973], and NSAIDs (p<0.005), OR 2.558, 95% CI [1.383, 4.729]) were significantly associated with steroid sparing resolution. In conclusion, patient characteristics including a lupus diagnosis and Hispanic race were associated with resolution and steroid sparing resolution, as were treatments including systemic NSAIDs and TNF-⍺ inhibitors. There were differences in medication utilization among specialty types, and patients with scleritis may benefit from ophthalmologic consultation. Future prospective studies will further elucidate the relationship between these factors and patient outcomes.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 10/12/2022

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