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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