Fungal panophthalmitis presenting as severe posterior scleritis

Purpose

To report a highly unusual and fulminant case of infectious fungal panophthalmitis that initially presented as angle closure in the setting of posterior scleritis, culminating in the loss of the affected eye.

Observations

A 57-year-old woman with a history of poorly controlled diabetes mellitus and autoimmune disease presented with a unilateral flat anterior chamber, highly elevated intraocular pressure (50-65 mmHg) and severe chemosis of the right eye. Initial VA was NLP in the affected eye. An ultrasound B-scan revealed a very pronounced T-sign and severely thickened posterior sclera and choroid indicative of posterior scleritis. Bloodwork showed elevation of WBC count to 18 K/μL and broad spectrum antibiotics were initiated. However, a comprehensive infectious workup including fungal cultures were persistently negative. After three days of IV NSAIDs and antibiotics, WBC count normalized and pain had mildly improved. After consultation with a multidisciplinary team that included the Glaucoma, Retina/Uveitis, Infectious Disease, Rheumatology and Internal Medicine services, high dose IV methylprednisolone was started. Despite the initial improvement, corneoscleral decompensation and paralimbal perforation of the globe occurred. The eye was enucleated, and pathologic examination revealed a dense focus of budding yeast in the vitreous cavity.

Conclusions and importance

Scleritis is a rare entity, with posterior scleritis, infectious scleritis, and fungal scleritis representing increasingly rare subtypes. However, fungal scleritis may be underdiagnosed due to a number of factors including culture negativity, a lack of clinical suspicion, as well as the disease's propensity to masquerade as other pathologies such as angle closure or malignant glaucoma. Fungal scleritis should be considered in cases that present with possible infectious etiology, worsen with systemic corticosteroid treatment, or worsen despite broad-spectrum antibiotic coverage. When treating patients with underlying risk factors such as uncontrolled diabetes mellitus, recent antibiotic use, use of total parenteral nutrition, or immunosuppression, a higher level of suspicion for fungal etiology is also appropriate. In the outpatient setting, fungal eye infections do not always present with critical systemic illness or culture positivity. If there is suspicion for fungal involvement, early aqueous or vitreous tap may improve diagnostic yield.

Alterations in choroidal circulatory dynamics and choroidal thickness before and after treatment in posterior scleritis

BACKGROUND

Posterior scleritis is an inflammatory reaction of the sclera that occurs posterior to the ora serrata. The aim of this study was to present a case of posterior scleritis and to analyze choroidal circulatory and structural changes using laser speckle flowgraphy (LSFG) and optical coherence tomography (OCT), respectively.

CASE PRESENTATION

A 64-year-old man presented to our department because of hyperemia of the left eye for one week, diplopia, ocular pain, and distorted vision when looking leftward. At an initial examination, his best-corrected visual acuity was 1.0 Oculi uterque (OU), with mild conjunctival hyperemia oculus dexter (OD) and marked ciliary hyperemia oculus sinister (OS). Color fundus photographs revealed a cluster of choroidal folds extending from the macula to the inferior retinal region OS. Swept-Source OCT showed choroidal thickening OD, and bacillary layer detachment and paracentral middle maculopathy on the paracentral side of the optic nerve papilla, suggesting severe inflammation. Fluorescein angiography showed hyperfluorescence in the optic disc and window defects around the macula OU. Indocyanine green angiography showed mottled choroidal vascular hyperpermeability findings in the late stage. B-mode echography displayed thickening of the posterior wall of the left eye. Orbital magnetic resonance imaging showed the thickened posterior eyeball. The patient was diagnosed with posterior scleritis, and 30 mg of oral prednisolone was then given and tapered off over the next 4 months. The hyperemia and intraocular inflammation resolved after the treatment. The rate of change in macular blood flow assessed by the mean blur rate on LSFG was 20.5% and 20.2% decrease OD and OS, respectively, before and after treatment. The central choroidal thickness showed 8.8% and 37.8% decrease OD and OS, respectively.

CONCLUSION

Posterior scleritis complicated with choroiditis was suggested to show different choroidal circulatory dynamics from those in other choroidal inflammations.

A Review of Canine Episclerokeratitis and Scleritis

Episcleritis is synonymous with episclerokeratitis although the latter is most appropriate as the cornea is often affected as well as the episclera. Episcleritis is a superficial ocular disease characterized by inflammation of the episclera and conjunctiva. It responds most commonly to topical antinflammatory medications. In contrast scleritis is a granulomatous fulminant panophthalmitis that will progress rapidly and induce significant intraocular disease including glaucoma and exudative retinal detachments without systemic immune suppressive therapy.

Posterior Scleritis in a Patient with Psoriasis Masquerading as Acute Angle Closure Glaucoma

Posterior scleritis is a relatively uncommon form of scleral inflammation of the posterior segment of the eye. Clinical manifestations include ocular pain, headache, pain with ocular movements, and loss of vision. A rare presentation of the disease is acute angle closure crisis (AACC) with elevated intraocular pressure (IOP) secondary to anterior displacement of the ciliary body. Various systemic diseases have been described to co-exist with posterior scleritis; however, psoriasis has not been associated with posterior scleritis. Here, we present a case of posterior scleritis which initially presented as AACC in a patient with pre-existing psoriasis. A 50-year-old male with a history of psoriasis under treatment presented to the emergency department with intense sudden ocular pain and loss of vision on the left eye as well as headache and nausea. A thorough medical and ocular history was taken, and a detailed examination of the anterior and posterior segment was completed including visual acuity and IOP. Initial diagnosis of AACC was made, and appropriate actions were taken with partial resolution of his symptoms. However, upon further work-up including ultrasound (B-scan) of the left eye a final diagnosis of posterior scleritis was made. The patient was treated with steroids and nonsteroidal anti-inflammatory drugs which dramatically improved his condition. Photographic evidence of initial presentation and post-treatment condition was obtained and presented in this report. Posterior scleritis is a potentially vision-threatening condition which is usually challenging to diagnose. In this report, we highlight the challenges one might come into when dealing with different manifestations of the same disease, increasing awareness. This case of posterior scleritis presenting as AACC in a patient with a history of psoriasis enhances what we already know from the literature as well as provides some new insights in the clinical manifestations of posterior scleritis in the setting of psoriasis without arthritis.

Mucosal associated Lymphoid Tissue Lymphoma of the uvea: an analysis of 3 cases

Background

Ocular mucosa-associated lymphoid tissue (MALT) lymphoma involving orbit and conjunctiva usually has an indolent clinical course with “salmon patch” mass as typical presentation. This study is to report a series of rare cases and investigate the clinical and pathological features of ocular MALT lymphoma that involved uveal tissue primarily and presented as posterior scleritis.

Methods

This retrospective, observational study was conducted at Beijing Tongren Hospital. From 2018 to 2020, 3 cases of 3 eyes (2 female patients and 1 male patient) with ocular MALT lymphoma that involved uveal tissue primarily and presented as posterior scleritis were included in the study. All patients had complaints of red eyes with blurred vision. The average age was 56.33 ± 2.08 years old and the average time from initial diagnosis to pathological diagnosis was 3.00 ± 1.73 months. Ophthalmic examinations including best-corrected visual acuity (BCVA), intraocular pressure (IOP), slit lamp microscope examinations, fundus photography, B-scan ultrasonography, ultrasound biomicroscope (UBM), optical coherence tomography (OCT), fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) were conducted. Systemic workups including orbital magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT) and blood autoimmune antibody tests were also conducted. Pathological tissue from patients were obtained through surgeries. Biopsy examinations were performed to accurately determine pathological diagnosis. All the information of clinical, imaging and pathological changes were collected and analyzed.

Results

At the initial diagnosis, the BCVA of involved eyes decreased seriously while the IOP were normal. All involved eyeball showed extensive hyperemia and local thickening in the wall of eyeballs. B-scan ultrasonography showed mass with abundant blood and irregular cysts inside the eyeball wall and in the retrobulbar orbit, surrounding the ocular wall and optic nerve. UBM showed solid lesions with low and medium echo under the conjunctiva and inside the ciliary body of 2 cases. OCT showed posterior polar wavy rise of RPE and local neuroepithelial detachment in all cases. FFA and ICGA showed vascular abnormalities (patch-like strong fluorescence and fluorescence leakage) and local thickening in retina and choroid (Rectangle-like weak fluorescence below the macula). The posterior wall of the eyeball was thickened and enhanced in MRI. PET-CT also showed thickening of posterior wall of eyeballs and increased metabolic activity but there was no sign of autoimmune disease. All patients were diagnosed as MALT lymphoma through pathologic examinations of biopsy tissue.

Conclusions

The onset of primary ocular MALT lymphoma in uvea is hidden. The early clinical manifestations are lack of specificity and misleading. B-scan ultrasonography has characteristic manifestations and is valuable in diagnosis. However, pathological diagnosis through tissue biopsy is irreplaceable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02598-2.

Bilateral posterior scleritis after sequential bilateral cataract surgery: a case report

Background

Posterior scleritis is a rare, inflammatory ophthalmic disease, leading to severe visual impairment if untreated. Posterior scleritis occurring after surgery, unrelated to systemic inflammatory diseases, is even rarer. This report discusses a case of bilateral posterior scleritis, after cataract surgery in both the eyes, treated with high-dose steroids.

Case presentation

A 55-year-old man, who had undergone bilateral sequential cataract surgery one week before, presented with sudden loss of vision and ocular pain in both eyes. The patient had no systemic diseases or neurological symptoms. Serous retinal detachment of the macula with optic disc swelling was observed on fundus examination in both the eyes, and bilateral thickening of choroid and sclera was seen in ultrasonography. Under diagnosis of bilateral posterior scleritis due to the increased signal of sclera in both the eyes on magnetic resonance imaging, high-dose steroid therapy was performed. After treatment, improvement in visual acuity and retinal detachment were observed, and thereafter, it has been maintained without relapse.

Conclusions

With high-dose steroid therapy, we successfully treated a rare case of bilateral posterior scleritis following cataract surgery in both eyes. To our knowledge, this is the first report on posterior scleritis occurring after surgery, unrelated to systemic inflammatory diseases.

Choroidal involvement in non-infectious posterior scleritis

Purpose

To provide a comprehensive overview of choroidal involvement in non-infectious posterior scleritis; including different imaging modalities and their clinical usefulness.

Methods

Narrative review.

Results

Posterior scleritis is an uncommon yet potentially sight-threatening inflammation of the sclera. During the disease process, inflammation can spread to the adjacent choroid, causing different manifestations of choroidal involvement: (1) increased choroidal thickness, (2) choroidal vasculitis, (3) presentation as a choroidal or subretinal mass in nodular posterior scleritis, and (4) choroidal folds, choroidal effusion and exudative retinal detachment.

Conclusions

Clinical characteristics and multimodal imaging can aid in diagnosing and monitoring disease progression and response to treatment in non-infectious posterior scleritis with choroidal involvement.

Comparison of the clinical features between posterior scleritis with exudative retinal detachment and Vogt-Koyanagi-Harada disease

PURPOSE

This study aims to analyse the differences in clinical characteristics between VKH disease and PS with exudative retinal detachment (ERD).

METHODS

The medical records of 18 eyes of 12 patients with PS accompanied by ERD and 32 eyes of 16 patients with VKH disease were retrospectively reviewed.

RESULTS

Single ERD was more common in PS, while hyperreflective dots, multiple ERD, retinal pigment epithelium folds were more common in VKH disease on OCT. Both posterior coat thickness and choroid thickness were higher in VKH eyes. "T" sign was observed in 6 of 18 eyes (33.3%) in the PS group, whereas in none of the eyes of VKH disease. No significant differences were shown in FA imaging between PS and VKH cases. Relapse occurred in 12 eyes (66.7%) in PS group, mainly in the posterior segment, while 6 eyes (18.8%) experienced recurrence in the anterior segment in VKH group.

CONCLUSION

There are characteristic differences in multimodal imaging parameters and clinical course between VKH and PS with ERD.

Posterior scleritis and acute posterior multifocal placoid pigment epitheliopathy: A case of painful chorioretinitis and review of the current literature

Purpose

To describe a patient who developed concurrent acute posterior multifocal placoid pigment epitheliopathy (APMPPE) and posterior scleritis.

Observations

We describe a middle-aged woman that developed eye pain and photopsia. She was found to have a “T-sign” on ultrasound of the right eye and multiple, nearly confluent, ill-defined subretinal whitish lesions in both eyes. After an extensive laboratory evaluation and neuroimaging, her photopsia, pain with eye movements, and subretinal lesions began to regress on high dose systemic corticosteroids.

Conclusions and Importance

This is the first reported case of bilateral APMPPE and concurrent posterior scleritis. Our case highlights the importance of performing a full review of systems, specifically eliciting neurological changes, and dilated eye examination in all new uveitis cases.

Bilateral posterior scleritis presenting as acute primary angle closure: A case report

BACKGROUND

Scleritis is a rare disease and the incidence of bilateral posterior scleritis is even rarer. Unfortunately, misdiagnosis of the latter is common due to its insidious onset, atypical symptoms, and varied manifestations. We report here a case of bilateral posterior scleritis that presented with acute eye pain and intraocular hypertension, and was initially misdiagnosed as acute primary angle closure. Expanding the literature on such cases will not only increase physicians' awareness but also help to improve accurate diagnosis.

CASE SUMMARY

A 53-year-old man was referred to our hospital to address a 4-d history of bilateral acute eye pain, headache, and loss of vision, after initial presentation to a local hospital 3 d prior. Our initial examination revealed bilateral cornea edema accompanied by a shallow anterior chamber and visual acuity reduction, with left-eye amblyopia (> 30 years). There was bilateral hypertension (by intraocular pressure: 28 mmHg in right, 34 mmHg in left) and normal fundi. Accordingly, acute primary angle closure was diagnosed. Miotics and ocular hypotensive drugs were prescribed, but the symptoms continued to worsen over the 3-d treatment course. Further imaging examinations (i.e., anterior segment photography and ultrasonography) indicated a diagnosis of bilateral posterior scleritis. Methylprednisolone, topical atropine, and steroid eye drops were prescribed along with intraocular pressure-lowering agents. Subsequent optical coherence tomography (OCT) showed gradual improvements in subretinal fluid under the sensory retina, thickened sclera, and ciliary body detachment.

CONCLUSION

Bilateral posterior scleritis can lead to secondary acute angle closure. Diagnosis requires ophthalmic accessory examinations (i.e., ultrasound biomicroscopy, B-scan, and OCT).

Scleritis and sclerokeratitis associated with IgA vasculitis: A case series

Purpose

To describe a case series of scleritis associated with IgA vasculitis (IgAV) at a tertiary referral center.

Observations

Three men with scleritis associated with IgAV were identified: one with anterior scleritis alone, one with anterior scleritis and peripheral ulcerative keratitis (sclerokeratitis), and one with anterior and posterior scleritis. Visual acuity was preserved except from the patient who developed posterior scleritis. Ocular pain was the main symptom at presentation. All patients had a previous history of palpable purpura, but only one was aware of his underlying IgAV. Laboratory results revealed microhematuria and proteinuria with normal urinary β₂ microglobulin levels and negative serum ANCAs. Skin or kidney biopsy demonstrated leukocytoclastic vasculitis or glomerulonephritis with dominant IgA immune deposits.

Conclusions and Importance

Although uncommon, IgAV should be included in the differential diagnosis of anterior scleritis alone or associated with peripheral ulcerative keratitis or posterior scleritis, even in systemically asymptomatic patients. Urinalysis should not be underestimated in assessment of scleritis to detect early stages of glomerular disease. Scleritis may be the first manifestation whose study may lead to the diagnosis of IgAV. Multidisciplinary approach is necessary to prevent irreversible organ damage such as renal failure.

Atypical Sympathetic Ophthalmia Presenting with Ocular Pain Associated with Posterior Scleral Involvement

Purpose: To describe an atypical case of sympathetic ophthalmia. Design: Case report.Results: A 37 -year-old female presented a 3-day long acute left retroocular pain and photophobia, 1 month after having undergone evisceration of the fellow eye. Upon exploration, the patient presented conjunctival injection, macular retinal folds with peripapillary subretinal fluid, and hypocyanescent choroidal spots on indocyanine green angiography. A sympathetic ophthalmia with a reactive posterior scleritis involvement was diagnosed. The patient underwent treatment with prednisone, mycophenolate, and cyclosporine with slowly tapering, presenting a total recovery over the years.Conclusion: Sympathetic ophthalmia may present itself atypically as ocular pain with little vision loss secondarily to a mild panuveitis with reactive scleral involvement.

Intravitreal dexamethasone implant — a new treatment for idiopathic posterior scleritis: A case report

BACKGROUND

Posterior scleritis is one of the most easily missed and misdiagnosed diseases in ophthalmology. In this case we treated a patient with intravitreal dexamethasone implant that has not been extensively studied before.

CASE SUMMARY

A 40-year-old female patient who had anxiety, palpitation, and insomnia presented with eye pain and decreased vision in the left eye. An eye examination indicated that her visual acuity (VA) was 40/100. Her left eye presented conjunctival edema, mild exophthalmos, clear cornea, KP(-), and clear aqueous humor. In the fundus, there was a cinerous retinal protuberance. Ultrasonography showed “T-sign” and no systemic association was detected in laboratory examination. One month after injection of dexamethasone implant, the patient exhibited VA of 20/20, fundus serous retinal detachment disappeared, and intraocular pressure of both eyes was at the normal level.

CONCLUSION

Intravitreal injection of dexamethasone implant may be a safe and effective treatment for patients with idiopathic posterior scleritis.

Monocular posterior scleritis presenting as acute conjunctivitis: A case report

BACKGROUND

Posterior scleritis is a rare inflammatory ocular disease, characterized by severe and painful inflammation of the sclera. It is often misdiagnosed or underdiagnosed, due to its general and varying clinical presentation profile, which primarily involves pain and visual impairment but which can include eyelid edema, choroidal folds, serous retinal detachment, disc edema, hard exudates in fovea and subretinal mass. We report here a case of posterior scleritis, with symptoms of eye pain and red eye, initially misdiagnosed as acute conjunctivitis.

CASE SUMMARY

A 56-year-old man presented to a local hospital with complaint of pain and redness in the right eye. The initial diagnosis was acute conjunctivitis and he was given antibiotic eyedrops. Upon week-long continuance of the symptoms despite treatment, he presented to our hospital. Initial examination revealed a shallow anterior chamber in the right eye and vision reduction to 0.6. Further testing by optical coherence tomography, ultrasound biomicroscopy, and fundus photography indicated diagnosis of posterior scleritis. The patient was given methylprednisolone (oral) on a tapered reduction schedule (starting with 70 mg/d). According to the peaks and troughs of symptoms, compound betamethasone injection was administered into the bulb, culminating in discontinuation of the oral corticosteroid. Subsequent optical coherence tomography showed the subretinal fluid near the optic disc to be completely absorbed after treatment.

CONCLUSION

Posterior scleritis should be among the differential diagnosis of eye pain and redness, and diagnosis requires further ophthalmic accessory examination, such as by optical coherence tomography.

A case of giant cell arteritis presenting with nodular posterior scleritis mimicking a choroidal mass

Purpose

Herein we present a case of giant cell arteritis presenting with nodular posterior scleritis and exudative retinal detachment mimicking a choroidal mass.

Observations

A 67-year-old man presented with sudden onset left-sided periorbital pain, blurry vision, and a choroidal lesion in the posterior pole. Despite treatment with high-dose oral prednisone for suspected nodular posterior scleritis mimicking a choroidal mass, the vision in his left eye did not recover, and he developed optic nerve pallor on exam. Further evaluation revealed an ESR of >140 mm/hr (Upper limit of normal = 20 mm/hr), a CRP of 113 mg/L (Upper limit of normal = 9 mg/L), and a temporal artery biopsy consistent with GCA. The patient was started on methotrexate and the oral steroids were slowly tapered.

Conclusions

Given the potential for GCA to present with scleritis and the potential for nodular posterior scleritis to mimic a choroidal mass, presence of a painful choroidal lesion with optic nerve swelling should prompt an evaluation for GCA to prevent permanent and bilateral vision loss.

Posterior Scleritis in Familial Mediterranean Fever

Purpose

Familial Mediterranean fever (FMF) is a monogenic autoinflammatory disease presenting as sporadic paroxysmal attacks of fever and abdominal pain. The inflammation of serosal spaces, joints, and skin is caused by the production of an abnormal protein called pyrin. Ocular pathology is scarce in FMF.

Case Report

Herein we describe a case of FMF presenting with painful loss of vision in the left eye. Serous macular detachment assessed by OCT, leaky pinpoint subretinal foci temporal to the fovea examined by fluorescein angiography, scleral and choroidal thickening seen on ultrasonography, and a negative systemic workup for vasculitis established the diagnosis of FMF-related posterior scleritis. The posterior scleritis responded promptly to moderate-dose oral corticosteroids with return of vision to baseline and resolution of the subretinal fluid.

Conclusions

FMF rarely involves the posterior pole. Visual loss in FMF results from either posterior scleritis or posterior uveitis. A high degree of suspicion of posterior scleritis is warranted in female patients with known FMF presenting with cloudy serous macular detachment.

Usefulness of B-scan ocular ultrasound images for diagnosis of optic perineuritis

Purpose

This study was performed to examine the usefulness of B-scan ocular ultrasound images for the diagnosis of optic perineuritis.

Observations

A 72-year-old woman developed nonpainful blurred vision in her left eye. At the first ophthalmological consultation, she had optic disc swelling and choroidal folds in both eyes and subretinal fluid in the left eye. She was referred to our clinic 1 month after symptom onset. At the first visit to our clinic, she still complained of blurred vision. She was found to have mild vitreous cells in the left eye and optic disc swelling in both eyes. However, the choroidal folds had already resolved in both eyes. B-scan ultrasound images displayed the optic nerve sheath as a highly reflective circle with shadowing around the optic disc in both eyes and scleral thickening in the left eye with fluid in sub-Tenon's space. Bilateral optic perineuritis with posterior scleritis seemed highly plausible. Magnetic resonance imaging with intravenous contrast revealed increased signal intensity around the optic nerve (i.e., the “tram track sign”) in both eyes, which was consistent with optic perineuritis.

Conclusion and importance

Optic perineuritis is a rare inflammatory disorder involving the optic nerve sheath. Although magnetic resonance imaging is reportedly useful for diagnosis of this disease, no previous reports have described B-scan ultrasound imaging for this purpose. We herein provide the first report of a patient suspected to have optic perineuritis based on B-scan images. B-scan ultrasound may be useful for diagnosis of optic perineuritis, especially with inflammation surrounding the optic nerve.

Intravitreal bevacizumab (avastin) as an adjuvant for the treatment of posterior scleritis

We report a case of posterior scleritis effectively managed with intravitreal bevacizumab. A 71-year-old woman was diagnosed with posterior scleritis. Although she was initially treated with systemic steroids, her clinical presentation deteriorated. She was then treated with a single intravitreal injection of bevacizumab and aqueous humor collection. The aqueous level of vascular endothelial growth factor prior to the intravitreal injection was 880.51 pg/mL, greater than that in the healthy control group (p < 0.001). One month later, the scleritis was completely resolved, and the patient remained stable during six months of follow-up. Intravitreal bevacizumab appears to be an effective adjuvant therapy for patients with posterior scleritis.