Posterior Scleritis
-Posterior scleritis is a rare inflammatory condition of the eye which is a diagnostic challenge because of its diverse clinical presentation
-Female predominance
-Mean age of presentation is around 45 years
-Unilateral but in a third of patients, is bilateral
-Symptoms: eye pain, headache, pain with ocular movements, and loss of vision if not treated timely
-Clinical signs are nonspecific: conjunctival chemosis, hyperemia, and optic nerve swelling
-The eye may also be without visible redness if inflammation is only posterior, making the diagnosis even more challenging
-The condition may masquerade as other ocular pathologies, emphasizing the need for a keen clinical eye to identify its distinct features.
D/D: Acute angle closure glaucoma, orbital/pre-septal cellulitis, orbital masses such as orbital pseudotumor also known as idiopathic orbital inflammation, rhabdomyosarcoma, leukemia, and neuroblastoma
-About 40-50% of scleritis are associated with systemic diseases
-The inflammatory condition most commonly associated is RA, but SLE and GPA are commonly linked
-Other etiologies of scleritis include infections (namely, varicella zoster virus (VZV) and herpes zoster virus (HZV)), orbital trauma, and medications such as bisphosphonates
-These patients are usually co-managed with a rheumatologist and an ophthalmologist
DIAGNOSIS:
-Slit lamp exam: inflammation of the anterior sclera with conjunctival chemosis, vessel dilation, and tortuosity
-Fundus: Optic nerve edema, serous RD, choroidal thickening and chorioretinal folds
-OCT may show choroidal thickening in active disease and is a useful tool to track disease course, with a reduction of thickening when treated effectively
-B-scan ultrasonography shows choroidal and scleral thickening greater than 2.5 mm, as well as fluid in sub-Tenon's space known as the pathognomonic T-sign
-MRI further compliments the diagnostic arsenal offering a more detailed anatomical outline and is useful when ultrasound is non-conclusive
-Certain laboratory tests can aid in the diagnosis of this condition, such as a serologic test for rheumatic diseases such as an anti-nuclear antibody (ANA), rheumatoid factor antibody (RF), anti-citrullinated antibody (CCP), and ANCA
MANAGEMENT:
-Oral corticosteroids: prednisolone is 1 mg/kg/day with weekly tapering depending on the clinical response
-Pulse IV corticosteroid in vision-threatening cases
-Methotrexate: first-choice steroid-sparing therapy
-Other steroid-sparing agents are azathioprine and mycophenolate for their tolerability and more rapid steroid-sparing effect when compared to methotrexate
-Cyclophosphamide is another agent used, but primarily in patients with systemic vasculitis such as GPA
-Biologic therapy: TNF-alpha inhibitors, Rituximab, newer biologic agents such as tocilizumab an interleukin-6 inhibitor
www.ophthalmobytes.com
Image from Rajan Eye Care Hospital
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