^{1, 2}Suad Hannawi, ³Maria Al-Salmi, ¹Haifa Hannawi

¹Al Kuwait-Dubai (Al Baraha) Hospital, Emirates Health Services (EHS), ²Ministry of Health and Prevention (MOHAP), Dubai, ³Medical and Health Sciences, Sharjah University

Introduction: Scleritis is a serious painful inflammatory eye disease that might result in visual loss. Around 50% of scleritis patients have an underlying systemic autoimmune disease of which Rheumatoid arthritis contributes to the majority (RA).

Tocilizumab is an Interleukin 6 (IL-6) inhibitor biological medication approved to treat adults with moderately to severely active rheumatoid (RA), with some case series that it might be effective in treating eye scleritis in RA patients. But not no case report demonstrated a positive response of scleritis to tocilizumab in RA patients with failure to multiple Biological disease-modifying anti-rheumatic drugs (bDMARD).

Method(s): We report  67 years old female of Indian ethnicity, who had non-infectious scleritis (secondary to RA) refractory to multiple biological DMARD but responded to Tocilizumab treatment.

Result(s): TN is a 67 years old female of Indian ethnicity, who has suffered from RA for 5 years, under the care of the Rheumatology clinic in Al Kuwait-Dubai (Al Baraha) Hospital. At the beginning of the RA, she was treated with Methotrexate 25 mg Qwk and Sulphasalazine 1 g TID, with no response. Followed by Adalimumab (anti-tumor Necrosis factor; anti-TNF)  40 mg a week. RA musculoskeletal symptoms and signs, and the laboratory inflammatory markers responded to adalimumab. But, despite the response to adalimumab, she developed left eye non-infectious anterior scleritis that had been confirmed by an ophthalmologist. The scleritis was active and persistent, despite adding systemic corticosteroid.  Therefore, Adalimumab was changed to Etanercept (anti-TNF), which has been used for 6 months. Again, there was a good MSK response and normalization of the inflammatory marker to Etanercept with no improvement in the scleritis. After which, Etanercept had been changed to Rituximab; a monoclonal antibody (anti-B-lymphocyte antigen CD20). Scleritis responded to the Rituximab with complete resolution of the scleritis and improvement in visual acuity.

The response to Rituximab continued for 3 years. After which, the scleritis recurs again. The patient started to complain of a reduction in the visual acuity.

In an attempt to hinder the scleritis and the inflammation in the eye (Figure. 1). Tocilizumab had been started. One month after starting the Tocilizumab the redness of the eyes improved (Figure. 2) and the patient started to have visual acuity improvement.

Conclusion(s): Tocilizumab might be an alternative treatment for RA patients with scleritis failing other biological treatments. Long-term studies are required to establish the safety and efficacy of Tocilizumab in treating non-infectious scleritis related to RA.

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