The authors present an interesting case report of recurrent anterior scleritis. Circulating IgA and IgG auto-antibodies directed against tissue transglutaminase, endomisium and gliadin are frequently elevated in patients with coeliac disease. The classic symptoms remain chronic diarrhoea, malabsorption syndromes and abdominal discomfort, but there are also rarer systemic findings, including aphthous stomatitis and dermatitis herpetiformis. There is case report evidence of an association between coeliac disease and recurrent or chronic uveitis. The patient described is a healthy 37-year-old woman who was referred to clinic for management of recurrent refractory scleritis in her right eye of unknown aetiology. Her first episode in 2007 resolved with topical steroid treatment. Her second episode a year later needed treatment with oral steroids. She was found to have normal autoimmune blood tests. In 2009 she was first seen in the clinic with recurrence of right eye pain despite being on topical treatment. She also reported recurrent gastrointestinal upset. She underwent examination and extensive testing, including normal digestive endoscopy, colon biopsy and abdominal magnetic resonance imaging. As she had become asymptomatic, tapered withdrawal of the steroid drops was planned. In 2010 she presented with a new recurrence needing high dose oral steroids. She could not tolerate methotrexate or azathioprine so was started on salazopirine. Despite this her inflammation and ocular pain remained. As she continued to complain of recurrent gastrointestinal symptoms, she was once again screened for gastrointestinal diseases in 2011 when high anti-transglutaminase IgA antibodies were found and hydrogen breath test with d-xylose was positive. She was prescribed a strict gluten-free diet, which relieved her ocular and gastrointestinal symptoms. Systemic steroids were slowly tapered and discontinued. Since starting the gluten free diet she has only had one flare of ocular pain, which she puts down to inadvertent exposure to gluten. The authors speculate that an association may be mediated by the intrascleral deposition of immune complexes leading to tissue inflammation, similar to the pathogenesis of dermatitis herpetiformis where dermal intrapapillary deposition of IgA leads to neutrophil infiltration. Coeliac disease should be considered in the differential diagnosis of scleritis associated with gastrointestinal symptoms.

Anterior scleritis and coeliac disease: a proposed association.
Keller J, Torres-Torres R, Sainz de la Maza M.
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Saruban Pasu

Moorfields Eye Hospital, London, UK.

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