Clinical Profile of Scleritis in Children

Purpose: To describe the clinical pattern of scleritis in patients ≤16 years of age at a tertiary care eye hospital in India.

Methods: The medical records of 24 eyes of 20 children with scleritis were included in this retrospective study. Collected data included age, subsets of uveitis, best corrected visual acuities (BCVA), detailed laboratory investigations and treatment.

Results: Mean age at presentation was 12.2 ± 2.5 years. Scleritis was unilateral in 80% patients and an equal gender distribution was observed. Posterior scleritis (41.7%) was the most common subtypes of scleritis and nodular scleritis was the most common type of anterior scleritis (33.3%). Necrotizing scleritis was seen in 16.7% eyes. Tuberculosis was the only systemic association and found in three (15%) patients.

Conclusions: Clinical profile of scleritis in children can be different from that of adults.     

Clinical Features of Scleritis Across the Asia-Pacific Region

Purpose: To examine the spectrum of scleritis in four tertiary institutions across the Asia-Pacific.

Methods: Clinical records from 354 patients were reviewed from centers in Australia, Singapore, and India, excluding those with insufficient data (n = 24).

Results: Indian patients presented younger (41.5 ± 13.4 years) than Australians (50.8 ± 17.5) and Singaporeans (48.6 ± 15.9), with fewer women (49% vs 62%/57%). Diffuse disease was universally most common. Autoimmune and infectious disease proportions were similar in Australia (31%/10.3%) and Singapore (27.5%/8.3%) but reversed in India (8.3%/30%). Necrotizing scleritis was most frequently associated with infection (27.3%). Presumed ocular tuberculosis accounted for 75% of infectious cases in India. Posterior scleritis had the highest complication rate (82.4%) and immunosuppressants used per patient (0.98 ± 0.31 95% CI).

Conclusions: Clinical presentations of scleritis vary across the Asia-Pacific, particularly in endemic regions for tuberculosis such as India, where it affects younger men with a predominance of nodular and infectious disease.     

Infectious scleritis: Clinical spectrum and management outcomes in India

In this retrospective case series, we studied the predisposing factors, causative organisms, clinical spectrum, and outcomes of 12 cases of culture-proven infectious scleritis. Nine of 12 patients had a history of preceding trauma (surgical or accidental). Past surgical history included small-incision cataract surgery (4), pterygium surgery (1), and trabeculectomy (1). Six patients had multifocal scleral abscesses due to Pseudomonas, Klebsiella, or Nocardia. Only 2 patients retained useful vision (>6/18). A poor visual acuity at presentation usually resulted in a worse visual outcome (P = 0.005). Four eyes developed phthisis. The addition of surgical intervention did not result in a significantly better visual outcome than medical management alone (P = 0.209), but resulted in a higher globe preservation rate (P = 0.045). Therefore, we concluded that infection must be ruled out in cases of scleritis with preceding history of trauma, and aggressive surgical intervention improves the anatomical outcome but does not change the visual outcome.     

Transient visual symptoms in systemic lupus erythematosus and antiphospholipid syndrome

PURPOSE: To review the potential pathogenic mechanisms of transient visual symptoms (TVS) in the course of systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), to discuss the most common clinical features associated with the occurrence of TVS, and to explore possible treatment options for these patients. METHODS: The literature regarding the clinical and laboratory characteristics of SLE and APS patients experiencing TVS is reviewed from 1979 onward. A brief review of the wide spectrum of ophthalmologic features occurring in SLE and APS is also provided. RESULTS: Data emerging from the review process point to thromboembolism as the most probable cause of TVS in SLE and APS. Thromboembolisms are likely induced by cardiac valve abnormalities and should be treated with anticoagulant drugs. CONCLUSION: While progress has been made in understanding the association of TVS with SLE and APS, further investigation is needed to clarify this interesting relationship.     

Pattern of Scleritis in an Egyptian Cohort

Purpose: To report the clinical experience with scleritis at four Egyptian tertiary care eye centers.

Methods: Multicenter retrospective chart review of all patients with scleritis visiting four ocular inflammation referral clinics in Egypt between January 2013 and October 2017.

Results: A total of 303 scleritis patients were enrolled. These included 76 male and 227 female patients. The most frequent subtype of scleritis was nodular anterior scleritis (44.9%). Rheumatoid arthritis and Wegener granulomatosis were the 2 most common systemic associations among our cohort. Eyes with necrotizing scleritis with inflammation had the lowest mean initial and final BCVA.

Conclusion: The visual prognosis of an eye with scleritis varies with the subtype of scleral inflammation. In our cohort, it was found to be poorer in eyes with necrotizing scleritis with inflammation compared to other subtypes.     

A case of giant nodular posterior scleritis mimicking choroidal malignancy

To report a case of giant nodular posterior scleritis mimicking a choroidal tumor. A 42-year-old lady with systemic hypertension presented with a 1-week history of unilateral visual loss, pain and redness in her left eye. Examination showed sectoral anterior episcleritis in her left eye as well as a dome-shaped choroidal mass at the inferior-temporal periphery, associated with retinal hemorrhages and subretinal fluid. Systemic evaluation and imaging of the choroidal mass were performed and could not rule out amelanotic choroidal melanoma. At the same time, she was prescribed a 2-week course of oral nonsteroidal anti-inflammatory drug (NSAID) for her sectoral anterior episcleritis. The choroidal mass was found to have resolved completely right before her scheduled fine needle biospy. Diagnosis of nodular posterior scleritis and a trial of oral NSAID can be considered in patients presenting with a choroidal mass before any invasive procedure.     

Syphilitic Scleritis and Choroidal Malignant Melanoma of the Same Eye

A 42-year-old Italian homosexual presented with a red painful eye associated with exudative retinal detachment that was subsequently attributed to syphilitic posterior scleritis. These findings all resolved with intravenous penicillin therapy. However, choroidal mass lesion persisted and subsequent ancillary imaging including B scan and ultrasonography confirmed the presence of a choroidal melanoma, which was treated with radioactive plaque therapy. This case report will describe the interesting findings of this unique presentation.     

Calcification at the posterior pole in scleritis

We report a case with unilateral recurrent anterior scleritis which developed sclerochoroidal calcification at the posterior pole without any overt sign of posterior scleritis during the follow-up period of nine years. We believe that subtle posterior scleral inflammation might lead to sclerochoroidal calcification which might be dystrophic in nature.     

Anterior Scleritis Associated with Pemphigus Vulgaris

We present a rare co-occurrence of anterior scleritis developing in a patient with recalcitrant pemphigus vulgaris. We discuss the clinical and therapeutic implications of these two conditions and offer concise recommendations.     

The clinical features of posterior scleritis with serous retinal detachment: a retrospective clinical analysis

AIM: To summarize the clinical features, systemic associations, risk factors and choroidal thickness (CT) changing in posterior scleritis (PS) with serous retinal detachment. METHODS: This retrospective study included 23 patients diagnosed PS with retinal detachment from August 2012 to July 2017. All patients’ medical history and clinical features were recorded. The examinations included best corrected visual acuity (BCVA), intraocular pressure (IOP), fundus examination, and routine eye examinations. Posterior coats thickness (PCT) was determined by B-scan ultrasound, the CT was measured by enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) and clinical data were compiled and analyzed. RESULTS: After application of extensive exclusion criteria, 23 patients with PS remained (13 females, 10 males). The average age at presentation was 29.5±9.24 years old. Ocular pain and blurred vision were the two most common complained symptoms by patients. Anterior scleritis occurred in 12 patients, which was confirmed by ultrasound biomicroscopy (UBM) examination. Despite all patients displaying serous retinal detachment in their macula, no fluorescein leakage was observed in the macular area. Optic disc swelling was documented in 10 of the 23 eyes. From B-scan ultrasound examination, the PCT increased with fluid in Tenon’s capsule demonstrated as a typical T-sign. The average PCT was 2.51±0.81 mm in the PS-affected eyes and only 1.09±0.29 mm in the unaffected eye (P<0.0001). The subfoveal CT was 442.61±55.61 μm, which correlated with axis length (r=-0.65, P=0.001) and PCT (r=0.783, P<0.001). The BCVA and IOP did not correlate with either CT or PCT. CONCLUSION: PS with serous retinal detachment presented a variety of symptoms, such as pain, visual loss, and physical indicators. Typical T-sign detected by B-scan ultrasound is a useful confirmatory sign for PS diagnosis. Pathological increases in CT might be a potential predictive factor for inflammation.     

Multifocal Surgically Induced Necrotizing Scleritis Following Strabismus Surgery: A Case Report

Purpose: To present clinical findings of a 28-year-old woman with multifocal surgically induced necrotizing scleritis following uncomplicated strabismus surgery.

Method: A 28-year-old woman underwent uncomplicated strabismus surgery of her right eye for sensory exotropia under general anesthesia (6 mm right medial rectus muscle resection and 8 mm right lateral rectus muscle recession).

Design: Retrospective, observational case report and literature review.

Results: One month after strabismus surgery, the patient presented with surgically induced necrotizing scleritis in the nasal aspect of sclera. Bacterial culture of the bed of the scleral melt showed no growth and all laboratory evaluation was normal. The scleritis completely resolved after initiation of systemic corticosteroids and oral azathioprine. Three weeks later (after tapering dose of systemic medication), the patient returned with large area of necrotizing scleritis in the same eye, but this time in the temporal aspect of sclera.

Conclusion: To our knowledge, this is the first documented case of multifocal surgically induced necrotizing scleritis occurring after strabismus surgery. This study also highlights the fact that scleritis may recur even in an area distant from the site of surgery, despite initial control. It seems that maybe with a longer course of treatment it is less likely to recur, and tapering medications should be carefully managed.     

Squamous cell carcinoma with necrotizing scleritis

Purpose: To report on a case of limbal squamous cell carcinoma (SCC) with necrotizing scleritis in a young, previously healthy, white Australian male. Methods: A 31-year-old man presented with a left limbal lesion intermittently causing a red eye and foreign body sensation. He had enjoyed surfing for many years. Repeat HIV tests were negative and the lesion was biopsied. Results: Biopsy showed a well-differentiated SCC apparently arising in an intra-epithelial (in situ) carcinoma of the conjunctiva. The lesion was excised and a corneoscleral graft repair was performed. Conclusion: The present case highlights the potential for a significant increase in the prevalence of ocular surface neoplasia in healthy young people who have had excessive UV-B exposure.     

The Diagnosis and Management of Scleritis

Necrotizing scleritis is an uncommon condition, and failure to diagnose it or treat it adequately is so disastrous that every ophthalmologist should know how to recognize and manage it.     

Experience of scleritis and episcleritis at a tertiary center in Southern Taiwan

Purpose:

The purpose of this study was to review the clinical experiences of scleritis and episcleritis in Southern Taiwanese people during a 7-year period.

Methods:

The charts of 89 patients (representing 101 eyes) who had visited our clinic from January 2003 to July 2010 were retrospectively reviewed. They were diagnosed as having episcleritis or scleritis. The medical charts, slit lamp photographs, and laboratory data were reviewed. Age, gender, laterality, previous surgery history, systemic diseases, follow-up duration, and ocular complications were collected. The patients were classified as having clinically suspected noninfectious scleritis (CSNIS), clinically suspected infectious scleritis (CSIS), and episcleritis for analysis.

Results:

In the series of 89 patients (i.e., 101 eyes), 31 (34.8%; 32 eyes) patients had scleritis and 58 (65.2%; 69 eyes) patients had episcleritis. Episcleritis and scleritis occurred slightly more frequently in women than in men. In the 31 patients (32 eyes) diagnosed with scleritis, 12 (38.7%) patients had CSIS and 19 (61.3%) patients had CSNIS. Patients with scleritis were older than patients with episcleritis (p < 0.001). Previous pterygium excision was associated with CSIS and necrotizing scleritis.

Conclusion:

Scleritis occurred in a more elderly population. It was more frequently associated with ocular complications, compared to episcleritis. Both CSNIS and CSIS were associated with a history of pterygium excisional surgery. Our series of patients had a high occurrence of necrotizing scleritis. All cases of necrotizing scleritis were associated with a history of previous ocular surgery.     

Nocardia asteroides Necrotizing Scleritis Associated with Subtenon Triamcinolone Acetonide Injection

Purpose: To report a case of Nocardia asteroides infection after subtenon triamcinolone acetonide injection. Design: Case report. Results: An 80-year old female received a subtenon triamcinolone acetonide injection for postcataract surgery cystoid macular edema. Shortly after, the patient developed a chronic red eye that progressed to a fulminant necrotizing scleritis. Eventual scleral biopsy revealed Nocardia asteroides infection, which improved after 5 months of systemic antibiotic therapy. Conclusions: Subtenon triamcinolone acetonide injection should be recognized as a cause of serious infectious scleritis.     

Fungal Scleritis with Exudative Retinal Detachment

Purpose: To report a case of fungal scleritis associated with exudative retinal detachment.

Design: A rare case report.

Methods: Nonresolving fungal scleritis mimicking noninfective scleritis was treated with systemic and topical antifungals and low topical steroids after diagnosis was established on scleral scraping. Even after complete resolution of scleritis, exudative retinal detachment persisted.

Results: The patient was advised of a possible need to undergo vitreo retinal surgery if exudative retinal detachment persisted for more than a month after complete resolution of the scleritis component.

Conclusion: Infective scleritis must be ruled out in cases of longstanding scleritis not responding to immunosuppressives.     

Scleritis in a Person with Stiff-Person Syndrome

Purpose: To describe a case of anterior scleritis in a patient with stiff-person syndrome. Methods: Case report. Results: A 55-year-old woman with stable stiff-person syndrome and off immunomodulatory therapy developed unilateral anterior scleritis, which resolved over three weeks with systemic nonsteroidal anti-inflammatory therapy. Conclusions: The authors are unaware of reports regarding the association of scleritis with stiff-person syndrome.     

Association of Low Vitamin D Levels with Noninfectious Uveitis and Scleritis

Purpose: To determine whether an association between Vitamin D and noninfectious ocular inflammation exists.

Methods: Retrospective case-control study with 765 patients (333 uveitis cases, 103 scleritis cases, 329 controls). Logistic regression models examined the relationship between hypovitaminosis D and ocular inflammation.

Results: The odds of having uveitis were 1.92 times higher for patients with hypovitaminosis D compared to patients with normal Vitamin D levels in the multivariate analysis [odds ratio (OR) = 1.92, 95% Confidence Interval (CI) = 1.36–2.72, p = 2.32 × 10^–4]. A secondary analysis demonstrated that the odds of developing uveitis or scleritis were 5% lower and 4% lower, respectively, for every unit increase in Vitamin D level (uveitis: OR = 0.95, 95% CI = 0.94–0.97, p = 9.87 × 10^–6; scleritis: OR = 0.96, 95% CI = 0.93–0.99, p = 0.009).

Conclusion: Hypovitaminosis D was associated with increased risk of ocular inflammation in this retrospective study.