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MULTI-NODULAR POSTERIOR SCLERITIS

MULTI-NODULAR POSTERIOR SCLERITIS. Dr Nilutpal Borah, M.S. Guwahati Eye Institute and Research Center Assam , India. 15 year old girl was admitted in a neurology hospital suspecting of intracranial lesion. Referred for eye examination. Ocular history OS –

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MULTI-NODULAR POSTERIOR SCLERITIS

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  1. MULTI-NODULAR POSTERIOR SCLERITIS Dr Nilutpal Borah, M.S. Guwahati Eye Institute and Research Center Assam , India

  2. 15 year old girl was admitted in a neurology hospital suspecting of intracranial lesion. Referred for eye examination.

  3. Ocular history • OS – 1 week- sudden , complete, painful loss of vision with swelling. • Pain around the left periorbital region, radiating towards left hemicranium, left ear and left side of the neck. • Nausea and vomiting .

  4. Past history • 5 months ago- OS – pain, redness, dimness of vision. Treatment was incomplete. • 1 year ago-OD - similar episode of pain & redness. No treatment .

  5. Clinical findings • Tender globe • VA -OD 6/6, OS PL negative (max illumination with IDO) • OS - RAPD + Lids swollen, mild superior conjunctival and episcleral congestion. flare +, cell+ , fibrinous deposition on crystalline lens

  6. Fundus- OD- vitreous cells + OS- vitreous cells ++, Several small and medium, yellowish, sub-retinal mass lesions. Retinal blot hemorrhage, exudative detachment. Disc – hyperaemic & edematous

  7. Investigations • Blood R/E - ESR 40 mm(1st hr) Hb 9.0% • Urine R/E - Albumin trace Pus cell 2-4/HPF Epithelial cells 1-2/HPF

  8. Investigations • Systemic examinations - unremarkable. • Paranasal sinuses - normal • CT Scan brain - normal • X - ray -chest - normal • Stool R/E - ova & cysts- absent • Montoux test - negative • VDRL - non-reactive • ANA -negative • HIV - negative • Retrovirus/HBsAg - negative

  9. FFA Early phase- multiple, irregular blocked fluorecscent spots with focal hyperfluorescence at the margins. Late phase - pooling of dye with minimal staining . Paravascular leakage. Disc - diffuse hyperfluorescence .

  10. B-scan ultrasonography • Multiple, irregular mass lesions involving choroid and sclera. Moderate to high internal reflectivity. • Choroid and sclera – grossly thickened • Peribulber edema - present • ‘T’ sign- positive

  11. B–scan showing resolution of scleritis

  12. Diagnosis OS – Multinodular posterior scleritis Anterior scleritis Inflammatory optic neuritis Exudative retinal detachment

  13. Treatment • Intra venous methyl prednisolone -1 gm daily X 5 days • Topical steroid & cycloplegic E/Drop

  14. Follow up 5 th day– VA – FC- 1 meter Slit-lamp and fundus examination showed improvement • Treatment continued with - Oral steroids(1mg/kg ), topical steroid eye drop

  15. Follow up 3 weeks – VA- 6/18p Slit-lamp and fundus examination –further improvement • Treatment continued

  16. 5 days after 3 wks after

  17. Discussion • Scleritis- inflammatory condition, characterized by edema and inflammatory cell infiltration of sclera. • More common in woman of 50-60 years. • 50% cases are associated with systemic diseases.

  18. Conclusion • Multinodular posterior scleritis is a rare disease. • Varied mode of presentation may complicate diagnosis. • Posterior scleritis in this young female patient responded well to I.V.methyl prednisolone and oral steroid.

  19. Problems • History of recurrence • Effective long term prevention of recurrence in this young adult patient • Role of TNF alpha i. e. infliximab, Etanercept, adalimubab in the treatment

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