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 –
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 .
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 .
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
FundusOD- vitreous cells +
OS- vitreous cells ++,
Several small and medium, yellowish, subretinal mass lesions. Retinal blot
hemorrhage, exudative detachment.
Disc – hyperaemic & edematous
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
Investigations
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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
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 .
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
B–scan showing resolution of scleritis
Diagnosis
OS –
Multinodular posterior scleritis
Anterior scleritis
Inflammatory optic neuritis
Exudative retinal detachment
Treatment
• Intra venous methyl prednisolone -1 gm
daily X 5 days
• Topical steroid & cycloplegic E/Drop
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
Follow up
3 weeks –
VA- 6/18p
Slit-lamp and fundus examination –further
improvement
• Treatment continued
5 days after
3 wks after
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.
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.
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