How would you approach management of nodular scleritis in the setting of suspected GCA?

Scleritis is probably a rare but real association with GCA. The rarity is such that I would not ignore alternative causes of scleritis. For example, ANCA-associated vasculitis could mimic GCA and syphilis has also been reported as a masquerade.

Scleritis is usually divided into 5 forms: nodular, diffuse, necrotizing, posterior, and scleromalacia perforans.

Scleritis should respond very well to oral prednisone. However, the average duration of scleritis is reported to be 7 years, so usually, a steroid-sparing drug is required. Generally, anything that controls the underlying disease will also control the scleritis. I am aware of at least one case report using tocilizumab to treat scleritis with GCA, but in other settings, alternative biologics like rituximab would be the drug of choice. (In scleritis secondary to RA, the biologic of choice is a monoclonal antibody to TNF). It is also possible that the duration of scleritis associated with GCA is shorter compared to some other causes, but no one has a series large enough to analyze this.

Some use a local injection of triamcinolone (done by an ophthalmologist) to control scleritis. But this is controversial because scleritis can cause scleral thinning and this could be exacerbated by the local injection.

If the scleritis is active despite a modest dose of prednisone and tocilizumab, I would probably consider adding methotrexate if there are no contraindications.