Episcleritis and Restatsis

[mrchemo]

As a child (I am now 30) I developed Still diesease s(some form of RA) I also developed at anterior uveitis, this would show up now and then, as I grew up the RA regressed and never did much than grumble.  3 weeks ago I developed a red right eye that would itch and be irritated, no pain or photophobia.  An eye doc, diagnosed Phlyctenular keratoconjunctivitis and since I know I am a steroid responder to dexamethaosone, gave me Zylet 4 times a day for a week then stoo this cleared it up.  The problem then returned a couple of days later and the doc gave me bacitracin, I used this for a week and had no effect.  I then returned to my doc and he took another look and says it is episcleritis and again gave me Zylet for 4 days and then switch to ACular for a week and then return to see him.  I also know that I am HLA B51 which is linked to Bechet's and that has been linked to Phlyctenular keratoconjunctivitis.  I have no active RA and havent since 2003, if the Acular doesnt work then he wants to try oral steroids, something I am not keen on.  I noticed that some people are using Restasis (i.e. cyclosporin) to treat Phlyctenular keratoconjunctivitis and was wondering whether it would work for episcleritis, this seemed to be a safer option than using oral steroids  and I guess my question is, would it work?  I know that restasis does't work for Uveitis since thats in the back of the eye, but since episcleritis is at the front I would have thought Restasis may be a better option?

[John C Hagan III, MD, FACS]

With your history, especially as a young adult you are at an increased risk for inflammatory/auto-immune/collagen-vascular problems. In much older individuals with a less active immune system these tend to become less of a problem.

If you have to have a problem with the eye it's much better its on the surface of the eye (like episcleritis and phlyctenular keratoconjunctivitis) than intra-ocular (inside the eye) uveitis.

Using Restasis for episcleritis is an 'off label' use of the medication and not one that the manufacturer lists as an indication. As you indicate there are various postings on the web about its use. It's a very safe medication (but slow in onset of action some 6-8 weeks in many cases). Your ophthalmologist would probably want to review the medical literature or/and discuss it with ophthalmologists (Eye MDs) with interest and expertise in 'external eye disease' or 'Uveitis specialists' before coming to a conclusion about using it.

There are other steroid eye drops that are forumulated for steroid responders that might be tried (example FML, Vexol, etc). Other options would be to use a non-steroidal anti-inflammatory eye drop there are several new and several old options.

This is a generalization but most ophthalmologists will only use oral steroids if all other options fail and the possibility of serious eye damage exists.  Normally episcleritis does not fall into the list of things oral steroids are used for.  You are well informed and you know that steroids are relatively safe for very short periods of time but used for a long time side effects occur in 100% of people that use them.

It would seem that you have a number of good alternatives to oral steroids.

JCH MD

[JACE25]

A related discussion, restasis was started.