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PubMed This is a summary of 20 peer-reviewed journal articles Updated
Ophthalmology

Treatment Strategy: Medical and Surgical Approaches

At a Glance

Scleromalacia perforans is treated by controlling the underlying immune or infectious cause and protecting the weakened eye wall. Severe thinning or perforation may require urgent graft surgery, while medicines require close blood-test and infection monitoring.

Treating scleromalacia perforans (SP) requires a two-pronged approach: “putting out the fire” in the immune system and, if necessary, “reinforcing the wall” of the eye through surgery. Because the eye wall is physically melting away, topical eye drops alone are never enough to stop the process [1].

The Medical Strategy: Calming the Immune System

For the vast majority of cases, SP is an autoimmune process where the body attacks its own collagen. The goal of medical treatment is to stop this attack before the eye wall becomes too thin to function [1][2].

  • Induction Therapy (The “Fire Extinguisher”): For rapidly progressive thinning or when a perforation is feared, doctors may start with “pulse” therapy—very high doses of intravenous methylprednisolone (a powerful steroid) for several days, followed by a slow taper of oral steroids [3][4]. These pulses are reserved for selected severe, vision- or organ-threatening disease.
  • Steroid-Sparing Agents: Because long-term steroid use has many side effects, doctors transition patients to “maintenance” medications. Cyclophosphamide is a specialist-selected option for severe necrotizing disease [5]. Other options include methotrexate, mycophenolate mofetil, or azathioprine [6][7]. Treatment depends on severity, systemic diagnosis, toxicity, reproductive goals, and specialist judgment.
  • Biologics: If standard medications don’t work, “biologic” drugs like rituximab (an IV infusion) or TNF-inhibitors (like adalimumab) may be used to target specific parts of the immune system [8][9].

Medication Safety: These medications require individualized baseline and follow-up monitoring. You will need regular blood tests to check blood counts, kidney, and liver function. Discuss vaccination and latent-infection screening (like TB or Hepatitis B) with your doctor. Because these drugs suppress your immune system, you are at a higher risk for infections; report fevers, chills, or new eye discharge to your doctor immediately.

The Surgical Strategy: Reinforcing the Eye

Surgery is not a cure for SP; rather, it is a tectonic (structural) repair to prevent the eye from rupturing. Surgery is usually only considered when the eye wall is dangerously thin, if there is a hole (perforation), or if the dark inner layer of the eye is bulging out (uveal prolapse) [10][11]. Perforation or impending perforation requires urgent surgical assessment. The primary goal is often to preserve the globe, and visual recovery can be uncertain.

Common surgical techniques include:

  • Scleral Patch Grafting: Using preserved donor sclera (the white of a donor eye) to “patch” the thin area [12].
  • Other Graft Materials: Depending on the size and location, surgeons may use pericardium (the tough sac around the heart), corneal tissue, or even synthetic materials [13][14].
  • Amniotic Membrane: This is tissue from a human placenta that is used as a biological “bandage” to help the surface heal and reduce inflammation [12][15]. It generally does not provide the tectonic strength needed to replace missing sclera in a deep defect or open globe.

When the Cause is Infectious

In rare cases, the “melting” isn’t caused by an autoimmune disease but by an infection (often following an old surgery or injury) [1][16]. In these cases, the treatment is the exact opposite of the autoimmune protocol:

  • Do Not Stop Steroids on Your Own: While steroids can make an infection worse by weakening the eye’s ability to fight germs [17][18], you must not abruptly stop systemic corticosteroids after ongoing treatment because of adrenal-insufficiency and rebound-inflammation risks. An ophthalmologist and rheumatologist may urgently adjust therapy after evaluating infection.
  • Aggressive Antimicrobials: Doctors use high-dose, fortified antibiotic or antifungal drops and sometimes IV medications directed by cultures [16][19].
  • Debridement: A surgeon may need to physically “clean” the dead tissue from the eye wall to remove the source of the infection [18][20].

Success in treating SP depends on close coordination between your eye surgeon and your rheumatologist. While medical therapy handles the underlying disease, surgical intervention provides the physical stability the eye needs to heal [1].

Common questions in this guide

Can eye drops alone stop scleromalacia perforans?
No. Scleromalacia perforans usually involves an immune attack on the sclera, and topical drops alone cannot stop the eye wall from thinning. Treatment typically requires specialist-directed medicines, with surgery considered if the wall is dangerously weak or perforated.
What medicines are used to treat scleromalacia perforans?
A doctor may use high-dose intravenous methylprednisolone for selected, severe, rapidly progressive cases, followed by oral steroids and a slower taper. Longer-term options can include cyclophosphamide, methotrexate, mycophenolate mofetil, azathioprine, rituximab, or a TNF inhibitor such as adalimumab; the choice depends on disease severity, the underlying diagnosis, treatment risks, and reproductive goals.
Why are blood tests and infection screening needed during treatment?
Immune-suppressing medicines can affect blood counts, kidneys, and liver, so regular tests help doctors detect problems early. Your care team may also review vaccinations and screen for hidden infections such as tuberculosis or hepatitis B; fever, chills, or new eye discharge should be reported promptly.
When does scleromalacia perforans require surgery?
Surgery may be needed when the sclera is dangerously thin, a hole has formed, or the dark inner layer of the eye, called the uvea, is bulging through the weakened wall. Actual or impending perforation needs urgent assessment by an eye surgeon. The operation reinforces or closes the eye wall and protects the eye, but it does not treat the underlying immune or infectious cause, and vision may not fully recover.
What graft materials can repair a thinned eye wall?
Surgeons may use preserved donor sclera, pericardium, corneal tissue, or a synthetic material, depending on the defect's size and location. An amniotic membrane can help the surface heal and reduce inflammation, but it usually does not provide enough structural strength for a deep defect or open eye. Your eye surgeon selects the material based on the eye's structure and urgency.
How is infectious scleromalacia perforans treated?
When infection is suspected, doctors use cultures and other tests to guide high-strength antibiotic or antifungal treatment, sometimes including intravenous medicine. A surgeon may remove dead, infected tissue, and steroids may need urgent adjustment because they can worsen infection. Do not stop long-term systemic steroids suddenly; the ophthalmologist and rheumatologist should manage changes safely.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Have we ruled out an infectious cause with cultures or imaging before starting my immunosuppression?
  2. 2.Given my history of rheumatoid arthritis, why is cyclophosphamide or rituximab being considered (or not) for my specific case?
  3. 3.If we start with high-dose intravenous steroids, what is our plan for tapering down to a maintenance medication?
  4. 4.At what specific level of thinning or 'bulging' (ectasia) would you recommend I have a tectonic graft surgery?
  5. 5.If I need surgery, which graft material—donor sclera, pericardium, or amniotic membrane—is best suited for my eye structure?
  6. 6.How will you and my rheumatologist coordinate to monitor my blood counts and organ function while I'm on these medications?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (20)
  1. 1

    Necrotizing Scleritis: A Review.

    Dutta Majumder P, Agarwal S, Shah M, et al.

    Ocular immunology and inflammation 2024; (32(7)):1405-1419 doi:10.1080/09273948.2023.2206898.

    PMID: 37279404
  2. 2

    Current Approach for the Diagnosis and Management of Noninfective Scleritis.

    Dutta Majumder P, Agrawal R, McCluskey P, Biswas J

    Asia-Pacific journal of ophthalmology (Philadelphia, Pa.) 2020; (10(2)):212-223 doi:10.1097/APO.0000000000000341.

    PMID: 33290287
  3. 3

    A Rare Presentation: Bilateral Necrotizing Scleritis in Primary Sjögren's Syndrome.

    Narain S, Pyare R, Rath PD

    Ocular immunology and inflammation 2025; (33(1)):146-148 doi:10.1080/09273948.2024.2347573.

    PMID: 38709210
  4. 4

    Sclerokeratitis and Secondary Glaucoma in Relapsing Polychondritis in a 30-Year-Old Asian Male Patient: A Case Report.

    Flores LKC, Siazon RR

    Cureus 2025; (17(2)):e79128 doi:10.7759/cureus.79128.

    PMID: 40109806
  5. 5

    Clinical Profile of Patients with Necrotizing Scleritis in a Tertiary Eye Care Center in Southern India.

    Dutta Majumder P, Ghose A, Chidambaram M, et al.

    Ocular immunology and inflammation 2018; (26(3)):412-416 doi:10.1080/09273948.2016.1223857.

    PMID: 27762661
  6. 6

    Clinical profile and management of granulomatosis with polyangiitis-associated scleritis from a tertiary care hospital in South India.

    Mohanan-Earatt A, Biswas J

    Indian journal of ophthalmology 2023; (71(1)):146-152 doi:10.4103/ijo.IJO_1411_22.

    PMID: 36588225
  7. 7

    Methotrexate for the treatment of noninfectious scleritis.

    Sands DS, Chan SCY, Gottlieb CC

    Canadian journal of ophthalmology. Journal canadien d'ophtalmologie 2018; (53(4)):349-353 doi:10.1016/j.jcjo.2017.11.009.

    PMID: 30119788
  8. 8

    Rituximab in the Treatment of Refractory Noninfectious Scleritis.

    Cao JH, Oray M, Cocho L, Foster CS

    American journal of ophthalmology 2016; (164()):22-8.

    PMID: 26766304
  9. 9

    Factors affecting the resolution of acute non-infectious anterior scleritis.

    Abdel-Aty A, Kombo N

    The British journal of ophthalmology 2022; (106(12)):1672-1677 doi:10.1136/bjophthalmol-2021-318808.

    PMID: 34210671
  10. 10

    Scleral Patch Graft With a Suture Reinforcement Technique in Surgical Management of Necrotizing Scleritis With Ectasia.

    Wen JC, Lam J, Banitt MR

    Cornea 2018; (37(7)):933-935 doi:10.1097/ICO.0000000000001598.

    PMID: 29664747
  11. 11

    Transplantation of autologous perichondrium with amniotic membrane for progressive scleral necrosis.

    Kim JT, Kim KW, Mun SK, et al.

    The ocular surface 2019; (17(3)):571-577 doi:10.1016/j.jtos.2019.05.004.

    PMID: 31112741
  12. 12

    Combined Tenonplasty and Scleral Graft for Refractory Pseudomonas Scleritis Following Pterygium Removal with Mitomycin C Application.

    Siatiri H, Mirzaee-Rad N, Aggarwal S, Kheirkhah A

    Journal of ophthalmic & vision research 2018; (13(2)):200-202 doi:10.4103/jovr.jovr_122_16.

    PMID: 29719651
  13. 13

    Etiology, surgical management, and outcomes of patients with scleral thinning.

    Sun N, Yuan H, Zhang H

    The Journal of international medical research 2026; (54(7)):3000605261463434 doi:10.1177/03000605261463434.

    PMID: 42396624
  14. 14

    A Rare Patient With Orbital Apex Syndrome, Anterior Uveitis, and Necrotizing Scleritis Due to Herpes Zoster Ophthalmicus.

    Aydin E, Balikoglu-Yilmaz M, Imre SS, et al.

    The Journal of craniofacial surgery 2016; (27(8)):e750-e752 doi:10.1097/SCS.0000000000003098.

    PMID: 28005810
  15. 15

    Isolation of acid from eye drop bottles being used by patients presenting with presumed scleritis.

    Iyer G, Agarwal S, Srinivasan B, Narayanasamy A

    Indian journal of ophthalmology 2018; (66(8)):1084-1087 doi:10.4103/ijo.IJO_82_18.

    PMID: 30038147
  16. 16

    Infectious Scleritis: Pathophysiology, Diagnosis, and Management.

    Yu J, Syed ZA, Rapuano CJ

    Eye & contact lens 2021; (47(8)):434-441 doi:10.1097/ICL.0000000000000813.

    PMID: 34224444
  17. 17

    Chronic necrotizing sclerouveitis caused by Alternaria doliconidium.

    Menean M, Nicolini N, Cimino L, et al.

    European journal of ophthalmology 2026; (36(1)):NP16-NP18 doi:10.1177/11206721251369539.

    PMID: 40956900
  18. 18

    A novel technique of full-thickness scleral debridement in fulminant necrotising infectious scleritis and its outcomes-a consecutive case series.

    Karkhur S, Soni D, Sharma B

    International ophthalmology 2022; (42(2)):581-592 doi:10.1007/s10792-021-02030-6.

    PMID: 34613564
  19. 19

    Etiology, Pathogens, Clinical Features and Treatment of Bacterial Scleritis.

    Chen X, Lv X, Yang L, et al.

    Seminars in ophthalmology 2023; (38(6)):521-528 doi:10.1080/08820538.2023.2177117.

    PMID: 36794923
  20. 20

    Pseudomonas Scleritis following Pterygium Excision.

    Chaidaroon W, Supalaset S

    Case reports in ophthalmology 2017; (8(2)):401-405 doi:10.1159/000478721.

    PMID: 28924436

This page is for informational purposes only and does not constitute medical advice. Treatment decisions for scleromalacia perforans, especially urgent surgery or immune-suppressing medicines, should be made with your ophthalmologist and rheumatologist.

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