Management strategies of noninfectious scleritis: An update

Noninfectious scleritis represents a spectrum of potentially vision-threatening inflammatory disorders frequently associated with systemic immune-mediated disease. Therapy is decided based on the location, severity, and presence of ocular complications and systemic associated diseases. Starting with nonsteroidal anti-inflammatory drugs to oral corticosteroids, the therapeutic armamentarium has widened to include oral immunomodulator therapy. Over the last decade, advances in immunology and targeted therapeutics have substantially altered management paradigms, particularly for refractory and necrotizing disease. This review provides an updated, clinically focused synthesis of contemporary management strategies in noninfectious scleritis, with particular emphasis on biologic agents, small-molecule therapies, and emerging targeted treatments. We first discuss the management which includes the existing large-body of evidence supporting systemic corticosteroids and conventional immunosuppressive therapy. We further review second-line therapies which include biological agents such as tumor necrosis factor-α inhibitors, interleukin-6 blockade, and B-cell-directed therapy. Newer agents such as Janus kinase inhibitors are reviewed in the context of early clinical experience and evolving safety data. The role of local therapies, surgical intervention as an adjunct to systemic immunomodulation, and management of common complications are also addressed. Finally, we highlight strategies for long-term monitoring, prognostic factors, and future directions, emphasizing the need for prospective trials and precision-based approaches. This review is intended for clinicians managing complex scleritis and aims to inform evidence-based, individualized care in contemporary practice.