First Author: M.Acar TURKEY
Co Author(s): G. Sungar G. Uney N. Unlu D. Hazirolan F. Ornek
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To report the poor outcome of a case with bilateral, posterior scleritis diagnosed lately as presented with painless visual loss and exudative retinal detachment (ERD)
Department of Ophthalmology, Ankara Training and Research Hospital, Turkey
A seventy-three year-old lady presented with an acute visual loss in the right eye. The visual acuity (VA) in the right eye (RE) was 20/400 and no light perception in the left eye (LE). The history of visual loss in the left eye was for 5 months. The intraocular pressures were 11 mmHg in both eyes. There was no hyperemia or pain in both eyes. On examination, cornea was clear with quiet anterior chamber, both eyes were phakic with mild corticonuclear cataract, 0.5 + cells in vitreous in both eyes. There was ERD in the inferior quadrants of the LE. B scan ultrasound examination revealed choroidal an scleral thickening in both eyes and retinal detachment in the lefte eye. In enhanced depth imaging optical coherence tomograhy (EDI-OCT) retinal pigment epithelium (RPE) layers were quite irregular with thick choroid in both eyes, shallow subretinal fluid in the RE and retinal detachment in the LE. The investigatigation for the possible causes of scleritis was negative and eritrocyte sedimentation rate was 56 mm fall/1st hour. Fluorescein angiography showed hyperfluorescence at the areas of retinal detachment and both optic discs.
One week after topical and oral steroid (1mg/kg) treatment the visual acuity increased to 20/63 in the RE with no subretinal fluid, a regular RPE line in EDI-OCT and thinner choroid and sclera in B scan ultrasound examination. The subretinal fluid in the left eye resolved totally in 6 months but with a persistent irregular RPE line. One year after the initial presentation, while tapering the oral steroid the VA decreased in the right eye with a recurrence of posterior scleritis in both eyes. Intravenous pulse steroid (methylprednisolone 1 gr) treatment was given for 3 days followed by oral steroid treatment (1 mg/kg). Visual acuity in the RE improved to 20/50. Oral Cyclosporin A (150 mg/day) treatment was initiated while tapering oral steroid slowly. The VA was 20/100 in the RE with no subretinal fluid and a regular RPE line in OCT but with an increase in corticonuclear cataract in the last visit. There was no subretinal fluid but irregular RPE line in EDI-OCT in the LE with an increase in corticonuclear cataract.
Posterior scleritis is one of the most commonly misdiagnosed conditions. The presentation of posterior scleritis with ERD without any other symptoms may be the reason of the delay in diagnosis. The better outcome with steroids and cyclosporin A treatment in the other eye highlights the importance of early treatment in this disease. EDI-OCT may help in early diagnosis by detecting the subretinal fluid and choroidal thickening together with B Scan ultrasound examination.