Is Methotrexate a Superior Alternative to Steroids or Placebo for Scleritis? A Systematic Review and Meta-Analysis on Efficacy and Safety.

BACKGROUND

Scleritis is a severe, painful inflammatory condition affecting the sclera. If untreated, scleritis can lead to significant ocular complications. Corticosteroids are often considered for the initial treatment of non-infectious scleritis. However, for steroid-resistant cases, cases requiring prolonged therapy, or to reduce steroid dependence, immunosuppressive agents, including methotrexate (MTX), are employed.

OBJECTIVES

This study compared the efficacy and safety of MTX versus steroids and placebo in treating scleritis.

METHODS

A comprehensive literature search was conducted via different databases. The search results were screened against prespecified eligibility criteria. The risk of bias in the included studies was appraised using the Newcastle-Ottawa Quality Scale and the risk of bias in nonrandomized studies with intervention (ROBINS-I). Data were then systematically extracted and analyzed.

RESULTS

The literature search yielded 558 records, of which 11 studies that met the eligibility criteria were included. MTX in scleritis treatment demonstrated significant efficacy for inflammation control (P = 0.003). However, its effect on visual acuity was insignificant (P = 0.689). Safety analysis revealed lower adverse event rates than azathioprine and insignificant differences with mycophenolate, with comparable discontinuation rates. Treatment response varies by scleritis subtype, with higher efficacy in non-necrotizing anterior scleritis.

CONCLUSION

The study revealed MTX's clinical significance in managing noninfectious scleritis. Significant results were observed in inflammation control and tolerability; however, the lack of randomized comparator studies limits conclusions regarding MTX's superiority over steroids or placebo. Future controlled trials are needed to confirm comparative effectiveness and refine treatment guidelines.