Case Presentation
Presenter Dr Sanil Sawant Moderator Dr Devendra Phalak
Case History
28 year old male Clerk by occupation
Chief Complaint
Diminution of vision in right eye since 8 days
Negative History
No history of trauma No history of redness, pain, swelling No history of joint pain No history of any systemic illness
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 NormalConjunctiva Normal NormalSclera Normal NormalCornea Clear Clear
AC Deep , Quiet Deep , Quiet
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 healthyFoveal reflex present
Fundus photos ( OU ) ( 26/09/2015 )
Advise
1) OD –OCT (Macula )2) OD –B Scan 3) Ocular oncology consultation
OD – OCT ( 26/09/2015 )
OD – OCT ( 26/09/2015 )
Ocular Oncology ( 29/09/2015 )
OD retinal elevation inferotemporal to the disc
Advise B Scan to rule out choroidal/ retrobulbar
mass Retina opinion
OD – B Scan ( 29/09/2015 )
Provisional Diagnosis and Advise
OD choroidal mass probably hemangioma OS Refractive error To Follow up after 2 months
Visit on ( 27/10/2015 )
Chief complaint of diminution of vision in right eye
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
OD Fundus photo ( 27/10/2015 )
OD B scan ( 27/10/2015 )
OD OCT (27/10/2015 )
OD OCT (27/10/2015 )
Advise ( 27/10/2015 )
• Blood investigations –Hb , CBC ,ESR , RBS ( Random )Peripheral Blood Smear
Visit ( 29/10/2015 )
Hb -12.4 gm/dl Neutophils – 49 %Lypmphocytes –41 %Monocytes-06Eosinophils-04Basophils -00ESR –18 PBS – negative BSL( random ) -90 mg/dl
FFA ( 29/10/2015 )
FFA ( 29/10/2015 )
FFA ( 29/10/2015 )
Diagnosis and Advise (29/10/2015 )
OD Posterior Scleritis Injection IV Methylprednisolone 1 gm for 3
days To follow up after 3 days
Review ( 02/11/2015 )
OD S/A 6/9 N 36OU Anterior segment was Status Quo
OD Fundus photo ( 02/11/2015 )
OD B Scan ( 02/11/2015 )
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
Follow up ( 10/11/2015 )
OD S/A 6/12 p N 36 p
Follow up ( 10/11/2015 )
Advise ( 10/11/2105)
IMPRESSION -Resolving posterior scleritis Tab prednisolone tapering weekly To continue rest treatment Follow up after 2 weeks
Follow up ( 24/11/2015)
OD S/A 6/9 , N 24
OD B Scan ( 24/11/2015 )
OD OCT(24/11/2015 )
OD OCT(24/11/2015 )
ADVISE ( 24/11/2015 )
To taper tablet Predinisolone To continue rest treatment as advised before Follow up after 3 weeks
Review ( 15/12/2015 )
OU SA- 6/9 N 6
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
weeksTo follow up after 6 weeks
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
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
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
Symptoms
Acute loss of vision Pain RednessAsthenopia
Benson W. Posterior Scleritis. Surv Ophthalmology 1988 S 32 :297 -316
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
B Scan
Thickening of posterior eye wall Edema in retrobulbar space T sign – fluid in subtenons space Serous retinal detachment Subretinal massOptic 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
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
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
Differential diagnosis of Fundus mass
Benson W. Posterior Scleritis. Surv Ophthalmology 1988 32 :297 -316
Laboratory test for associated systemic disease
By Jay H. Krachmer, MD, Mark J. Mannis, MD, FACS and Edward J. Holland, MD
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.
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
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
Intravitreal Antivegf
Korean J Ophthalmol. 2011 Aug;25(4):282-4
Complications
Vision lossOptic atrophyIrreversible macular changes
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