A Case of Refractory Posterior Scleritis with Marked Retinochoroidal Detachment Associated with Panuveitis.

An 84-year-old man presented with decreased right-eye visual acuity. Upon initial examination, the rightand left-eye visual acuities were 0.03 and 1.2, respectively; moreover, the right- and left-eye intraocular pressure was 12 mmHg and 13 mmHg, respectively. Examination revealed a shallow anterior chamber of the right eye, anterior chamber inflammation, vitreous opacity, and marked retinochoroidal detachment. Optical coherence tomography (OCT) revealed retinal detachment (RD) and choroidal folds; moreover, B-scan ultrasonography (B-scan) showed RD as well as thickened sclera with fluid in Tenon's space. Fluorescent fundus angiography revealed hyperfluorescence in the optic disc and vascular hyperpermeability in the right eye. The left eye lacked extra-ocular symptoms or abnormalities. The right ocular axis measured 23.4 mm with no apparent subretinal fluid migration due to positional changes. Accordingly, the patient was diagnosed with panuveitis associated with posterior scleritis and immediately started on 40 mg prednisolone, which improved his symptoms. However, at 3 post-treatment months, choroidal folds were observed and was restarted on 20 mg prednisolone. The choroidal folds subsequently disappeared, with a current visual acuity of 0.3 in the right eye and no recurrence. Our findings indicated the utility of accurate diagnosis of posterior scleritis by B-scan and prompt systemic steroid administration.

Scleral changes in systemic lupus erythematosus patients using swept source optical coherence tomography.

Purpose: This study aims to examine scleral thickness in patients with systemic lupus erythematosus (SLE) without clinically evident scleritis and episcleritis, utilizing swept-source optical coherence tomography (SS-OCT). Methods: This cross-sectional single center study compared scleral thickness (Nasal scleral thickness 1mm, 2mm, 3mm, 6mm from scleral spur; Temporal scleral thickness 1mm, 2mm, 3mm, 6mm from scleral spur) in 73 SLE patients without clinically evident scleritis and episcleritis and 48 healthy volunteers with SS-OCT. Further, we investigated the correlation between scleral thickness in SLE patients and various parameters including laboratory markers, disease duration, disease activity, and organ involvement. Results: Across all measured sites (nasal scleral thickness at distances of 1mm, 2mm, 3mm, and 6mm from the scleral spur, and temporal scleral thickness at the same distances), the scleral thickness in the SLE group was significantly greater than that in the control group (all p-values <0.001). SLE patients with a disease duration of 5 years or less exhibited a higher scleral thickness compared to those with a more prolonged disease duration. Patients with a higher erythrocyte sedimentation rate (ESR) had a thinner temporal scleral thickness. However, no significant associations were identified between scleral thickness and disease activity, organ involvement, or other laboratory markers. Conclusion: Scleral thickness measured by SS-OCT was higher in SLE patients than healthy controls. Changes in scleral thickness in SLE patients are related to disease duration and ESR. SS-OCT can detect asymptomatic structural changes in SLE patients and may be a useful tool in the evaluation of early scleral abnormality.

Anterior segment optical coherence tomography and ultrasound biomicroscopy in the diagnosis of subconjunctival mycosis mimicking nodular scleritis.

A female patient in her 20s presented with a bulbar conjunctival mass lesion that was diagnosed as nodular scleritis. It was treated with topical and oral steroids in another hospital. Imaging was done using anterior segment optical coherence tomography and ultrasound biomicroscopy, which helped to rule out scleritis and subconjunctival cysticercosis. Histopathology of the excision biopsy specimen revealed fungal filaments. Topical antifungals were started, and the condition resolved without recurrence after therapy. Although rare, infections should be considered in the differential diagnosis of conjunctival mass lesions. Imaging can help to rule out other entities and guide towards appropriate management.

Role of anterior segment optical coherence tomography in scleral diseases: A review.

BACKGROUND: Scleritis and episcleritis are an overlapping spectrum of diseases and accurate diagnosis is of utmost importance as the treatment and prognosis are vastly different. Predominantly a clinical diagnosis, the challenge lies in those cases with equivocal clinical features. Furthermore, clinical grading of scleritis is subjective and hence is neither very reliable nor reproducible. Existing modalities such as slit lamp examination and clinical photographs in scleritis describe macroanatomy but do not provide details on the microanatomy of the sclera. A recent adjusted algorithm for anterior segment optical coherence tomography (AS-OCT) imaging has improved the ability of this device to aid in the diagnosis of all the major forms of scleritis. PURPOSE: To highlight the role of AS-OCT in delineating various anatomical forms of episcleritis and scleritis and explore this tool in monitoring disease course and response to therapy. METHODS: A comprehensive literature search was carried out in various medical databases using keywords AS-OCT and scleritis; AS-OCT and episcleritis; anterior segment imaging in scleritis; scleritis and episcleritis; Recent advances in anterior segment imaging. Original articles and novel reports describing the potential role of AS-OCT in the diagnosis and management of scleritis and episcleritis were included. RESULTS: After a thorough assessment, it was clear that published literature lacks guidelines for uniform interpretation and also for classification and follow-up in scleritis. We describe a uniform protocol for AS-OCT image acquisition, interpretation of images and list the advantages and limitations. CONCLUSIONS: AS-OCT can be used to localize the level of scleral inflammation thus helping in the diagnosis of scleral inflammatory disease. It can be a valuable tool in studying progression.

Escleritis nodular anterior idiopática. Hallazgos biomicroscópicos y tomográficos / Idiopathic nodular anterior scleritis. Biomicroscopic and tomographic findings

Varón de 65 años, sin antecedentes patológicos, que presenta nódulo escleral nasal hiperémico doloroso sugestivo de escleritis anterior nodular, sin otros hallazgos

Optical coherence tomography versus ophthalmic examination findings in the management of anterior scleritis: A prospective study.

PURPOSE: The goal of this work was to analyze optical coherence tomography (OCT) findings compared to ophthalmic examination results in the management of anterior scleritis. METHODS: We carried out a prospective study including patients presenting with anterior scleritis who underwent complete clinical examinations and OCT at baseline and at the final follow-up visit. RESULTS: The mean age was 46years. The superior and temporal quadrants were clinically the most involved regions and showed the greatest thickness on the OCT images. Nodules were observed clinically in 6 patients, while OCT revealed them in 9 cases. OCT revealed 3 cases of sub-clinical necrosis. Separation of fibers, scleral edema, dilated vessels, fluid pockets and increased scleral thickness were the most common signs of the disease. Mean total scleral thickness and mean scleral-episcleral complex thickness were significantly improved after treatment (P=0.001 and P=0.00; respectively). Post-streptococcal syndrome (PSS) was diagnosed in 3 cases of non-necrotizing anterior scleritis. Necrotizing forms were low-grade and were associated with systemic diseases in 2 out of 3 patients. OCT signs persisted for a substantial time after resolution of clinical signs. CONCLUSION: OCT helped to distinguish necrosis and scleral nodules in subclinical cases. Non-necrotizing forms of scleritis supported the diagnosis of PSS, while necrotizing forms suggested systemic diseases. Complete resolution of a scleral inflammation could be followed more objectively with OCT than by clinical examination.

OCT de segmento intermedio / Intermediate segment OCT

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Treatment of Progressive Scleromalacia Perforans by Tectonic Enhancement With Lyophilized Equine Pericardium.

PURPOSE: To describe the off-label use of lyophilized equine pericardium for tectonic enhancement of the sclera in a case of progressive scleromalacia perforans. METHODS: An 82-year-old woman with a history of varicella zoster virus sclerokeratitis presented with a progressively expanding scleral thinning at the superonasal quadrant of the anterior sclera of her left eye. The eye was blind because of intractable glaucoma. To avoid perforation of the exposed choroid, a single layer of lyophilized equine pericardium was sutured over the scleral perforation. After performing a conjunctival peritomy in the involved superonasal area, the pericardium was trimmed, fixated on the anterior sclera with 4 Nylon 9 to 0 interrupted sutures, and tucked underneath the conjunctival pocket. The conjunctiva was adapted with 6 Vicryl 8 to 0 interrupted sutures. RESULTS: The postoperative course was uneventful. At 12 months after surgery, slit-lamp biomicroscopy showed a stable subconjunctival sheet covering the staphyloma, whereas anterior segment optical coherence tomography demonstrated thickening of the ocular wall, suggesting successful integration of the pericardium. CONCLUSIONS: Suturing of equine pericardium over a scleral defect was feasible allowing successful reinforcement of the staphyloma in a case of severe scleromalacia perforans.

Immunopathological Analysis of a Mouse Model of Arthritis-Associated Scleritis and Implications for Molecular Targeted Therapy for Severe Scleritis.

Scleritis involves inflammation of the sclera, which constitutes 75% of the wall of the eye. This pathology is often seen as an ocular lesion associated with systemic inflammatory diseases. Severe types of scleritis such as posterior scleritis require urgent immunosuppressive treatments, including molecularly targeted therapies to avoid permanent visual impairment. Which molecules should be selected as targets has remained unclear. To clarify the pathogenesis of scleritis and propose appropriate target molecules for therapy, we have established novel animal model of scleritis by modifying the Collagen-II Induced Arthritis (CIA) model. Immunization twice with collagen II emulsified with complete Freund's adjuvant (CFA) caused arthritis and scleritis. The clinical appearance resembled human diffuse scleritis. Histopathological analysis suggested that macrophages, plasma cells, deposition of immune complexes, and growth of blood and lymphatic vessels are involved in the pathogenesis of CIA-associated scleritis. In addition, we analysed the background diseases of posterior scleritis and responses to molecularly targeted therapies as a case series study. We inferred from both the animal model and case series study that targets should not be T cells, but factors inhibiting macrophage activity such as tumor necrosis factor (TNF) and interleukin (IL)-6, and molecules suppressing antibody-producing cells such as CD20 on B cells should be targeted by molecularly targeted therapies.

Nodular Posterior Scleritis Masquerading as a Subretinal Mass.

This is the case report of a 50-year-old female with no systemic comorbidities who presented to the eye clinic with a 1-month history of right-sided eye pain and visual loss. Examination revealed no signs of inflammation in the right eye, with no proptosis or conjunctival injection. A relative afferent pupillary defect was present with no inflammatory cells in the vitreous. On fundoscopy, there was a swollen disc, a large superior creamy white subretinal mass associated with a shallow overlying retinal detachment. B-scan ultrasonography confirmed the presence of a subretinal mass. Hematological investigations revealed an elevated erythrocyte sedimentation rate. Infective and autoimmune markers were negative. A diagnosis was made of nodular posterior scleritis and the patient was treated with intravenous corticosteroids initially, and subsequently switched to oral corticosteroids. There was complete resolution of the mass with optic atrophy as a result. Posterior nodular scleritis is an extremely rare potentially vision-threatening ocular condition that requires multimodal investigations to diagnose and treat appropriately.

An unusual case of Behcet disease with posterior scleritis: A case report.

RATIONALE: Posterior scleritis is an ocular inflammatory disorder that can be associated with both infectious and non-infectious immune reactions. Behcet disease is a chronic, relapsing, multisystemic inflammatory disorder with uveitis. There are no reported cases of posterior scleritis with Bechet disease. PATIENT CONCERNS: A 50-year-old man previously diagnosed with systemic Behcet disease presented with ocular pain and decreased vision in the left eye. DIAGNOSIS: Posterior scleritis associated with Behcet disease was diagnosed based on optical coherence tomography showing choroidal folds, as well as contrast computed tomography and ultrasound sonography demonstrating thickening of the posterior sclera. INTERVENTIONS: Treatment with systemic corticosteroids was initiated. Since inflammation relapsed during steroid tapering, anti-tumor necrosis factor-alpha (TNF-α) therapy was used in combination, and tapering of steroids was possible without recurrence of inflammation for 12 months. OUTCOMES: Posterior scleritis was resolved and visual acuity improved. With the continuation of TNF-α therapy, oral prednisolone was successfully tapered and discontinued. No relapse of inflammation was observed at follow-up 1 year after discontinuation of prednisolone. LESSONS: Ophthalmologists should be aware of the possibility of rare manifestation of posterior scleritis in patients with Behcet disease, and that combined use of systemic steroids and anti-TNF-α therapy may resolve the scleritis without recurrence of inflammation.

Point-of-Care Ultrasound in the Evaluation of the Acutely Painful Red Eye.

BACKGROUND: Visual loss, ocular pain, and red eye are common presentations to front-line physicians in the emergency department, urgent care centers, or the primary care office. In recent decades, point-of-care ultrasound (POCUS) has been used by clinicians at the bedside in the evaluation and management of a vast array of patients, including those with ocular complaints. CASE REPORT: A 33-year-old man presented to the emergency department with left eye pain for 4 weeks' duration. The physical examination revealed visual acuity of 20/400 in the affected eye and diffuse conjunctival injection with perilimbal sparing and scleral edema. Using POCUS, he was noted to have diffuse thickening of the globe wall in the symptomatic eye with a thin layer of fluid posterior to the globe in Tenon's space and mild enlargement of the optic nerve sheath diameter. He was ultimately diagnosed with posterior scleritis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Posterior scleritis carries the potential for significant visual impairment when the diagnosis is missed or delayed. POCUS findings can aid the front-line physician in making the diagnosis of posterior scleritis allowing earlier initiation of appropriate therapy and follow-up.

Necrotising scleritis, keratitis and uveitis in primary antiphospholipid syndrome.

Ocular manifestations of antiphospholipid syndrome typically include thromboembolic and neuro-ophthalmic complications. In this report we present a case of inflammation of the ocular coats in a patient diagnosed with antiphospholipid syndrome 16 years prior. We discuss management of the case and the possible aetiology of the rare association.

Monitorización de la escleritis posterior mediante tomografía de coherencia óptica Swept-Source / Posterior scleritis follow-up by Swept-Source optical coherence tomography

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Angiografía con verde indocianina en escleritis anterior / Indocyanine green angiography in anterior scleritis

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