Scleritis a case presentation

1. Case Presentation
Presenter Dr Sanil Sawant
Moderator Dr Devendra Phalak

2. Case History
 28 year old male
 Clerk by occupation

3. Chief Complaint
 Diminution of vision in right eye since 8 days

4. Negative History
 No history of trauma
 No history of redness, pain, swelling
 No history of joint pain
 No history of any systemic illness

5. Ocular examination(26/09/2015 )
Right Eye Left Eye
VA ( UA ) 6/18 p N18 6/9
VA ( PH ) 6/6 p 6/6
Best Corrected Visual
Acuity
6/6 N 18 6/6 N 6
Lids Normal Normal
Conjunctiva Normal Normal
Sclera Normal Normal
Cornea Clear Clear
AC Deep , Quiet Deep , Quiet

6. Iris Normal colour ,pattern Normal colour , pattern
Pupil 2 mm reacting to light 2 mm reacting to light
Lens Clear Clear
Lacrimal apparatus Reguritation on pressure
negative
Reguritation on pressure
negative
Intraocular pressure 14 mm of Hg 14 mm of Hg
Fundus Described in diagram Media –clear
C D R 0.4 : 1
Neuroretinal rim healthy
Foveal reflex present

7. Fundus photos ( OU ) ( 26/09/2015 )

8. Advise
 1) OD –OCT (Macula )
 2) OD –B Scan
 3) Ocular oncology consultation

9. OD – OCT ( 26/09/2015 )

10. OD – OCT ( 26/09/2015 )

11. Ocular Oncology ( 29/09/2015 )
 OD retinal elevation inferotemporal to the disc
 Advise
 B Scan to rule out choroidal/ retrobulbar mass
Retina opinion

12. OD – B Scan ( 29/09/2015 )

13. Provisional Diagnosis and Advise
 OD choroidal mass probably hemangioma
 OS Refractive error
 To Follow up after 2 months

14. Visit on ( 27/10/2015 )
 Chief complaint of diminution of vision in right eye

15. Visit ( 27/10/2015 )
RIGHT EYE LEFT EYE
BCVA FC 1 M , < N 36 6/6 N 6
Anterior segment Status Quo Status Quo
Fundus Described Below Status Quo

16. OD Fundus photo ( 27/10/2015 )

17. OD B scan ( 27/10/2015 )

18. OD OCT (27/10/2015 )

19. OD OCT (27/10/2015 )

20. Advise ( 27/10/2015 )
• Blood investigations –
Hb , CBC ,ESR , RBS ( Random )
Peripheral Blood Smear

21. Visit ( 29/10/2015 )
 Hb -12.4 gm/dl
 Neutophils – 49 %
 Lypmphocytes –41 %
 Monocytes-06
 Eosinophils-04
 Basophils -00
 ESR –18
 PBS – negative
 BSL( random ) -90 mg/dl

22. FFA ( 29/10/2015 )

23. FFA ( 29/10/2015 )

24. FFA ( 29/10/2015 )

25. Diagnosis and Advise (29/10/2015 )
 OD Posterior Scleritis
 Injection IV Methylprednisolone 1 gm for 3 days
 To follow up after 3 days

26. Review ( 02/11/2015 )
 OD S/A 6/9 N 36
 OU Anterior segment was Status Quo

27. OD Fundus photo ( 02/11/2015 )

28. OD B Scan ( 02/11/2015 )

29. Advise ( 02/11/2015 )
 Tablet Prednisolone 80 mg once daily * 1 week
 Tablet Ranitidine 150 mg 2 times daily * 1 week
 Tablet Calcium Carbonate with Vitamin D 500 mg
once daily * 1 week
 To review after 1 week

30. Follow up ( 10/11/2015 )
 OD S/A 6/12 p N 36 p

31. Follow up ( 10/11/2015 )

32. Advise ( 10/11/2105)
 IMPRESSION -Resolving posterior scleritis
 Tab prednisolone tapering weekly
 To continue rest treatment
 Follow up after 2 weeks

33. Follow up ( 24/11/2015)
 OD S/A 6/9 , N 24

34. OD B Scan ( 24/11/2015 )

35. OD OCT(24/11/2015 )

36. OD OCT(24/11/2015 )

37. ADVISE ( 24/11/2015 )
 To taper tablet Predinisolone
 To continue rest treatment as advised before
 Follow up after 3 weeks

38. Review ( 15/12/2015 )
 OU SA- 6/9 N 6

39. Advise (15/12/2015 )
 Impression of resolved posterior scleritis was made
 To taper tablet Predinisolone over 5 weeks
 Tablet Ranitine 150 mg 2 times a day * 5 weeks
 To follow up after 6 weeks

40. Classification of Scleritis ( Watson & Hayreh )
 Anterior
Diffuse
Nodular
Necrotizing with inflammation
Necrotizing without inflammation( scleromalacia
perforans )
 Posterior
Jay H. Krachmer, MD, Mark J. Mannis, MD, FACS and Edward J. Holland, MD

41. Introduction
 Posterior scleritis is defined as inflammation of the
scleral behind ora serrata
McClusky P , Watson P et al Posterior scleritis: Clinical features systemic
associations, and outcome in a large series of patients Ophthalmology
1999;106:2380–2386

42. McClusky P , Watson P et al Posterior scleritis: Clinical features systemic associations, and
outcome in a large series of patients Ophthalmology 1999;106:2380–2386

43. Symptoms
 Acute loss of vision
 Pain
 Redness
 Asthenopia
Benson W. Posterior Scleritis. Surv Ophthalmology 1988 S 32 :297 -316

44. Signs
 Nodule on anterior sclera if associated with anterior
scleritis
 Fundus signs
 Fundal mass
 Choroidal folds or retinal striae
 Exudative retinal detachment
 Cystoid macular edema
Benson W. Posterior Scleritis. Surv Ophthalmology 1988 S 32 :297 -316

45. B Scan
 Thickening of posterior eye wall
 Edema in retrobulbar space
 T sign – fluid in subtenons space
 Serous retinal detachment
 Subretinal mass
 Optic nerve head swelling
Biswas J, Mittal S, Ganesh SK, Shetty NS, Gopal. L. Posterior scleritis: Clinical profile and
imaging characteristics. Indian J Ophthalmol 1998;46:195-202

46. Fundus Fluorescein Angiography
 Initial mottling of choroidal background
 Followed by multiple pinpoint areas of
hyperfluorescein
Benson W. Posterior Scleritis. Surv Ophthalmology 1988 S 32 :297 -316

47. Fundus Fluorescein Angiography
 In middle and late phases of angiogram these foci leak
fluorescein into subretinal space
Benson W. Posterior Scleritis. Surv Ophthalmology 1988 S 32 :297 -316

48. Differential diagnosis of Fundus mass
Benson W. Posterior Scleritis. Surv Ophthalmology 1988 32 :297 -316

49. Laboratory test for associated systemic disease
By Jay H. Krachmer, MD, Mark J. Mannis, MD, FACS and Edward J. Holland, MD

50. First line therapy
Beardsley RM, Suhler EB, Rosenbaum JT, Lin P. Pharmacotherapy of Scleritis:
Current Paradigms and Future Directions. Expert opinion on pharmacotherapy.
2013;14(4):411-424.

51. Immunosupressive drugs
Beardsley RM, Suhler EB, Rosenbaum JT, Lin P. Pharmacotherapy of Scleritis:
Current Paradigms and Future Directions. Expert opinion on pharmacotherapy.
2013;14(4):411-424

52. Biological response modifier
Beardsley RM, Suhler EB, Rosenbaum JT, Lin P. Pharmacotherapy of Scleritis:
Current Paradigms and Future Directions. Expert opinion on pharmacotherapy.
2013;14(4):411-424

53. Intravitreal Antivegf
Korean J Ophthalmol. 2011 Aug;25(4):282-4

54. Complications
 Vision loss
 Optic atrophy
 Irreversible macular changes

55. THANK YOU