Embedded Episcleral Foreign Body Mimicking Nodular Anterior Scleritis.

A 56-year-old man was referred to our clinic for unilateral nodular scleritis unresponsive to systemic corticosteroids. A localized, nodular hyperemia on the nasal bulbar conjunctiva surrounding a central cyst-like lesion together with vascular engorgement was observed on slit-lamp examination of the left eye. No abnormal fundoscopic findings were noted. Surgical exploration revealed an embedded episcleral brown colored, soft to touch, splinter-like organic foreign body (FB) which was confirmed by the histopathological examination. Nodular hyperemia resolved during the postoperative follow-up period, and mild scar tissue accompanied by scleral thinning developed in the left nasal bulbar conjunctiva. Ocular injury associated with FBs may cause significant ocular morbidity depending on the nature and location of the FB. Severe visual disability may occur if left untreated. Subconjunctival FBs are rare and may present with a clinical picture mimicking episcleritis or scleritis. History of trauma involving a FB should always be assessed for an accurate differential diagnosis and appropriate management of patients with anterior scleritis.

Syphilitic scleritis and episcleritis: A review.

Scleritis and episcleritis are rare, but potentially sight-threatening forms of syphilis. To provide a full description of this neglected subset of ocular syphilis, we evaluated the English literature for reports of syphilitic scleritis and episcleritis, recording the demographics, clinical characteristics, serological data, management practices, treatment responses, and visual outcomes. Previously published descriptions of 44 patients with syphilitic scleritis (50 eyes) and 9 patients with syphilitic episcleritis (14 eyes) were identified. The predominant type of scleritis was anterior scleritis, accounting for 92.9% of cases, with nodular anterior scleritis being the most frequent subtype at 58.1%. Almost one-quarter of patients were co-infected with human immunodeficiency virus (HIV). Initial misdiagnosis was common and led to delays in initiating treatment with appropriate antibiotics. Visual outcomes were often good in both scleritis and episcleritis, irrespective of HIV infection status, although complications including scleral thinning, keratitis, and uveitis, along with permanent visual loss and an association with neurosyphilis, were reported. Response to antibiotic treatment was typically rapid, often within 1 week. With the rising global incidence of syphilis, testing patients with scleritis or episcleritis for this infectious disease is important to ensure prompt diagnosis and treatment for best ocular and systemic outcomes.

Bilateral Ocular Rosai-Dorfman Disease Presenting as Diffuse Anterior Scleritis with Multiple Enlarging Epibulbar Masses.

PURPOSE: To report a unique case of extranodal Rosai-Dorfman disease (RDD) presenting as bilateral scleritis, which progressed to multifocal epibulbar masses. METHODS: Retrospective chart review. RESULTS: A 35-year-old Asian man presented with progressive pain and redness in both eyes for 4 months. Examination revealed bilateral diffuse scleral congestion and areas of scleral thinning. The cornea and anterior chamber of each eye were unremarkable. Despite oral corticosteroid and immunosuppressive treatment, scleritis progressed to multifocal epibulbar masses. Tissue biopsy specimens revealed foamy macrophages with histiocytes staining positive for CD68 and S100, confirming a diagnosis of RDD. Systemic evaluation was unremarkable for lymphadenopathy or extranodal involvement. The patient was started on systemic chemotherapy and at last follow up after 1 year, all epibulbar lesions were completely resolved. CONCLUSIONS: Rosai-Dorfman disease can present as bilateral scleritis initially and develop epibulbar masses without any systemic involvement. Biopsy with immunohistochemical analysis can aid in the diagnosis.

Peripheral Subretinal Mass Complicating Necrotizing Anterior Scleritis in a Patient with Granulomatosis with Polyangiitis.

Anterior scleritis is rarely diagnosed with a peripheral amelanotic subretinal mass. We reported a rare case of a 31-year-old woman who was referred for suspected left eye choroidal melanoma. The patient had granulomatosis with polyangiitis with a history of treated left eye necrotizing anterior scleritis. Her left eye examination revealed 20/60 vision, superotemporal diffuse scleral injection, and thinning. Dilated fundus examination of the left eye showed a large peripheral amelanotic subretinal mass below the area of anterior scleritis, optic disc hyperemia, and subretinal fluid. The patient was successfully treated with intravenous methylprednisolone, rituximab infusions, and oral methotrexate. Two months after treatment, her vision improved to 20/20, with inactive anterior scleritis and a significant reduction in the subretinal mass with complete resolution of optic disc hyperemia and subretinal fluid. High index of suspicion of this atypical presentation of anterior scleritis is important to avoid aggressive modalities of treatment.

Tofacitinib in Scleritis: A Case Series.

PURPOSE: To report the use of tofacitinib in ten patients with scleritis where the traditional immunomodulation was not successful or could not be used. METHOD: A retrospective chart review. RESULT: Tofacitinib was successful in the treatment of scleritis in patients either recalcitrant to or intolerant to conventional therapy in 9 out of 10 cases reported here. Two patients had developed reactivation of herpetic infection after 1 month of starting tofacitinib. The duration from diagnosis of scleritis to the institution of tofacitinib therapy varied from 1 month to 60 months. Duration of follow-up varies from 2 months to 11 months. CONCLUSION: Tofacitinib can be used as an important future option for managing recurrent and recalcitrant cases of scleritis.

Nodular scleritis-a rare presentation of COVID-19& variation with testing.

PURPOSE: - To report a rare case of patient presenting with nodular scleritis and SARS-CoV2. OBSERVATIONS: This case highlights a unique presentation of SARS-CoV2 positive patient with nodular scleritis as a presenting feature. Patient initially had ocular symptoms and developed only mild systemic features subsequently which did not require hospitalization. COVID testing done at different time points showed variable results which correlated with the ocular features. This patient was followed up during quarantine using tele-ophthalmology. CONCLUSION AND IMPORTANCE: This case highlights a possible rare presentation of a SARS-CoV2 patient with nodular scleritis and also importance of tele medicine during these unprecedented times.

Nodular syphilitic scleritis: a rare and forgotten entity.

Ocular manifestations of syphilis are usually seen in the secondary or tertiary stages of the disease, which is a nonspecific inflammatory response. We report a case of unilateral nodular scleritis in a patient with late latent syphilis, which resolved with intravenous crystalline penicillin for 2 weeks, topical fluorometholone, and tobramycin eye drops for 3 weeks.

Cataract Surgery in the Setting of Scleritis.

Purpose: To report the clinical profile of cataract and its surgical management in a scleritis cohort from India.Methods: We conducted a retrospective review of medical records of 39 eyes of 32 consecutive patients with scleritis who underwent cataract surgery in a tertiary eye care institute.Results: The mean age at presentation was 50.9 ± 11.1 years and 65.6% of the patients were female. Five patients (15.6%) were ≤ 40 years of age. Necrotizing scleritis (56.4%) was the most common subtype of scleritis in this cohort followed by diffuse anterior scleritis (28.2%), nodular scleritis (12.8%). The preferred incision for phacoemulsification was clear corneal in 30 eyes (77%). In the immediate post-operative period, four eyes (10.2%) developed severe corneal edema, one eye had descemet membrane detachment. Anterior chamber reaction was observed in 18 eyes (46.1%). Fifteen eyes (38.4%) developed raised intraocular pressure and two required surgical intervention after 3 months of cataract surgery. Early posterior capsular opacification was observed in 5 eyes (12.8%) and cystoid macular edema in 2 eyes (5.1%).Conclusion: In addition to providing a distinct pattern of cataract, index study showed that long-term control of scleral inflammation prior to the cataract surgery remains the primary requisite for the successful outcome.

Bilateral nodular sclerokeratitis secondary to syphilis - A case report.

A 30-year-old female patient presented with bilateral anterior nodular sclerokeratitis and multiple erythematous skin lesions involving the face, trunk, arms, and legs. The patient had a history of temporary relief with steroids, however the lesions recurred. A dermatology consultation was sought and the patient was diagnosed to have syphilis, consequent to which she was started on benzathine penicillin and showed a dramatic improvement in both skin and ocular lesions. A high index of suspicion for syphilis should be kept in mind for patients presenting with nodular scleritis to initiate timely and appropriate management with penicillin.

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.

How a Devastating Case of Acanthamoeba Sclerokeratitis Ended up with Serious Systemic Sequelae.

A 35-year old soft contact lens wearer with a proven bilateral Acanthamoeba keratitis developed a nodular scleritis. Based on the stepladder approach described by Iovieno et al. [Ophthalmology. 2014 Dec;121(12):2340-7], nonsteroidal anti-inflammatory drugs, methylprednisolone, and later azathioprine were added to the antiamoebic treatment. Unfortunately, there was further deterioration and an endophthalmitis developed. Unbearable pain and concerns of spread to the brain urged an enucleation. Histopathological examination confirmed Acanthamoeba cysts in the cornea, sclera, retina, choroid, and vitreous body. As a side effect of the immunosuppressive treatment, the patient developed myopathy, pulmonary aspergillosis, and an avascular necrosis of the hip. Scleritis is a devastating complication of Acanthamoeba keratitis with a poor prognosis and a high enucleation rate. Acanthamoeba sclerokeratitis is, due to cyst-free biopsies, mostly assigned to an immune-mediated mechanism, justifying the use of immunosuppressive treatment. Scleritis in our case contributed to the extracorneal spread of Acanthamoeba. Our case is the first documented extracorneal spread of Acanthamoeba without previous surgery. Extracorneal spread of Acanthamoeba should be considered, even in the case of false-negative biopsies. We strongly recommend serial sections of the retrieved scleral specimen in case of negative histopathological examination to exclude an infection. Even when an immune-mediated scleritis is suspected, systemic immunosuppressive treatment should always be used with the greatest caution. Awareness of the side effects and monitoring by an experienced physician is mandatory.

Clinical profile of patients with anterior nodular scleritis in India.

PURPOSE: To report the clinical profile of a series of anterior nodular scleritis in Indian population. METHODS: We conducted a retrospective review of medical records of 140 eyes of 123 consecutive patients with nodular scleritis who presented to a tertiary eye care institute between 2007 and 2018. RESULTS: The mean age at presentation was 46.8 ± 13.1 years and 70.7% of the patients were female. Bilateral involvement was observed in 14% patients. The most common presenting symptom was redness (92.6%) and ocular pain (69.1%). Twenty-seven patients (22%) had some systemic association and rheumatoid arthritis (5%) was the most common autoimmune disease. Presumed ocular tuberculosis was diagnosed in 13% patients. Methotrexate was the most common immunosuppressive used in these patients and an additional immunosuppressive was required in 6.5% patients. Recurrence of inflammation was observed in 74.8% patients. Deterioration of vision noted in 2.8% eyes. CONCLUSION: Tuberculosis remains an important cause of nodular scleritis in India. Recurrence of scleritis is common in nodular scleritis and cases with non infectious nodular scleritis often require treatment with immune suppressives.

Pattern of Scleritis in an Egyptian Cohort.

Purpose: To report the clinical experience with scleritis at four Egyptian tertiary care eye centers. Methods: Multicenter retrospective chart review of all patients with scleritis visiting four ocular inflammation referral clinics in Egypt between January 2013 and October 2017. Results: A total of 303 scleritis patients were enrolled. These included 76 male and 227 female patients. The most frequent subtype of scleritis was nodular anterior scleritis (44.9%). Rheumatoid arthritis and Wegener granulomatosis were the 2 most common systemic associations among our cohort. Eyes with necrotizing scleritis with inflammation had the lowest mean initial and final BCVA. Conclusion: The visual prognosis of an eye with scleritis varies with the subtype of scleral inflammation. In our cohort, it was found to be poorer in eyes with necrotizing scleritis with inflammation compared to other subtypes.

Infectious Scleritis: What the ID Clinician Should Know.

Scleritis is an inflammatory process involving the outer coating of the globe which is characterized by focal or diffuse hyperemia, moderate to severe pain, and frequent impairment of vision. Most cases of scleritis are autoimmune in nature and are managed with topical and/or systemic corticosteroids. Infectious scleritis is a less common entity, occurring in 5%-10% of cases, and requiring directed antimicrobial therapy. We present a case of Nocardia farcinica anterior nodular scleritis diagnosed via positive culture of an excisional biopsy of a scleral nodule. The patient improved after combined surgical and medical therapy with amoxicillin-clavulanate and moxifloxacin for 12 months. Based on a literature review, a summary of reported cases of infectious scleritis is provided, and guidelines pertaining to diagnosis and management are offered.

Nodular scleritis as the eye manifestation in Behcet's syndrome.

We report a case of a 45-year-old female, who was diagnosed as Behcet's disease and presented to us with nodular scleritis in her right eye.

Alteraciones anatomopatológicas en la escleritis anterior nodular necrotizante / Pathological alterations in necrotizing nodular anterior scleritis

RESUMEN La presencia de la escleritis necrotizante es rara; necesita de un diagnóstico y de un tratamiento oportuno, ya que su curso es rápido, severo y destructivo de la integridad del globo ocular. Se presenta una paciente de 43 años de edad, quien requirió atención oftalmológica al presentar el ojo derecho rojo con intenso dolor. Se le encontraron 3 nódulos en la región antero-inferior escleral. Se le realizó punción-aspiración con aguja fina en los nódulos esclerales y se obtuvo un fragmento de uno de ellos para el corte histológico. En ambas muestras se observó infiltrado inflamatorio de linfocitos y neutrófilos con algunas células plasmáticas. Se le impuso tratamiento con prednisona oral (0,5 mg/kg/día), prednisolona colirio y azatioprina a dosis de 1,5 mg/kg/día. La evolución al mes fue satisfactoria con mejoría gradual de las lesiones. El tratamiento se mantuvo por 3 meses con chequeos hematológicos reiterados. Se disminuyeron posteriormente las dosis medicamentosas hasta su eliminación a los 6 meses. La curación de las lesiones fue total. No se encontró enfermedad sistémica en el chequeo clínico efectuado(AU)

ABSTRACT The presence of necrotizing scleritis is rare; it needs a diagnosis and an opportune treatment, since its course is fast, severe and destructive of the integrity of the eyeball. We present a 43-year-old patient who required ophthalmological attention when presenting the red right eye with intense pain. Three nodules were found in the antero-inferior scleral region. Fine needle aspiration was performed on the scleral nodules and a fragment of one of them was obtained for the histological section. In both samples, inflammatory infiltrate of lymphocytes and neutrophils with some plasma cells was observed. He was prescribed treatment with oral prednisone (0.5 mg /kg/day), prednisolone eye drops and azathioprine at a dose of 1.5 mg/kg/day. The evolution to the month was satisfactory with gradual improvement of the lesions. The treatment was maintained for 3 months with repeated blood tests. Drug doses were subsequently reduced until their elimination at 6 months. The healing of the injuries was total. No systemic disease was found during the clinical check-up(AU)