Clinical features and visual outcomes of scleritis patients presented to tertiary care eye centers in Saudi Arabia

AIM: To describe the clinical features, systemic associations, treatment and visual outcomes in Saudi patients with scleritis. METHODS: A retrospective chart review was performed for patients with scleritis presenting to two tertiary care eye hospitals in Riyadh, Saudi Arabia, from 2001 to 2011. Data were collected on the clinical features of scleritis, subtypes of scleritis, associated systemic disease, history of previous ocular surgery and medical therapy, including the use of immunosuppressants. Treatment outcomes were evaluated based on best-corrected visual acuity (BCVA) and response to treatment. RESULTS: Of the 52 patients included in the study, non-necrotizing anterior scleritis was the most common type of scleritis in 22 patients (42.3%), followed by posterior scleritis in 14 patients (26.9%). The majority of cases, 31 patients (59.6%), were idiopathic in nature. Systemic associations were present in 12 patients (23.1%). Infectious scleritis was confirmed in 6 patients (11.5%): 3 with bacterial scleritis after pterygium excision, 2 patients with scleritis related to tuberculosis and 1 patient with scleritis resulting from herpes simplex infection. For the various subtypes of scleritis, BCVA values after treatment and time to remission significantly differed (P<0.05, all cases). Systemic immunosuppressive therapies in addition to steroids were administered to 46.2% of all patients. The T-sign was present on B-scan ultrasonography in 9 (64.3%) of the 14 posterior scleritis patients. CONCLUSION: Non-necrotizing anterior scleritis was the most common subtype of scleritis. Final visual outcome and time to remission differed among the various scleritis subtypes.     

Paecilomyces lilacinus scleritis with secondary keratitis

PURPOSE: To report a case of Paecilomyces lilacinus scleritis with secondary keratitis after initially diagnosed immune-based scleritis. METHODS: An 82-year-old man was diagnosed with immune-based scleritis and treated with oral cyclophosphamide 50 mg twice daily. However, multiple scleral abscesses and a fibrinoid aqueous reaction developed 3 months later. Infectious scleritis was suspected. The culture from the necrotic sclera grew P. lilacinus. Despite treatment with antimicrobials, the infection progressed to the cornea. The medication included topical natamycin suspension 5% and fluconazole 2 mg/mL hourly, as well as oral itraconazole 100 mg daily. Debridement of the necrotic tissue and intracameral injection with amphotericin-B were performed. RESULTS: The infection resolved 4 months later, although its resolution was accompanied by development of phthisis bulbi, and the visual acuity remained light perception. CONCLUSION: Infection by P. lilacinus can occur in a patient with scleritis. Infectious scleritis is a particular risk in cases involving diabetes mellitus, prior scleritis, previous surgery, and immunosuppression. Early detection of the microorganism and aggressive treatment are necessary to eradicate such an infection; however, the prognosis for vision recovery can remain poor despite treatment.     

Episcleritis and scleritis: clinical features and treatment results

PURPOSE: To evaluate the clinical experience with episcleritis and scleritis at a tertiary care eye center. METHODS: Retrospective chart review. RESULTS: One hundred thirty-four patients with scleral inflammation were seen over a 12-year period. Thirty-seven patients had episcleritis, and 97 patients had scleritis. Ocular complications occurred in only 13.5% of patients with episcleritis but in 58.8% of patients with scleritis (P <.0001). No patient with episcleritis had a decrease in visual acuity, whereas 15.9% of patients with scleritis did. Only 16.7% of patients with episcleritis required more than topical corticosteroids for treatment, and these patients required oral nonsteroidal anti-inflammatory drugs. Conversely, 30.4% of patients with scleritis required nonsteroidal anti-inflammatory drugs, 31.9% oral prednisone, and 26.1% systemic immunosuppressive drugs (P <.0001). Necrotizing scleritis and posterior scleritis more often were associated with ocular complications, occurring in 91.7% and 85.7%, respectively, than were diffuse anterior scleritis and nodular anterior scleritis (P =.020). Patients with necrotizing scleritis and posterior scleritis were more likely to be treated with oral corticosteroids or immunosuppressive drugs (90% and 100%, respectively) than were patients with diffuse anterior scleritis and nodular anterior scleritis (56.4% and 21.4%, respectively, P =.002). CONCLUSIONS: Scleritis is a severe ocular inflammation, often associated with ocular complications, and nearly always treated with systemic medications. Nearly 60% of these patients will need oral corticosteroids or immunosuppressive drugs to control the disease.     

Sympathetic ophthalmia in Singapore: new trends in an old disease

Background Sympathetic ophthalmia (SO) is an uncommon uveitic condition that occurs after injury to the uvea of one eye and may occur after accidental ocular trauma or ocular surgery. We sought to investigate the common causes of SO in Singapore and the demographic profile as well as the final visual acuity after treatment in these patients. Methods This was a retrospective, non-comparative case series in which patients with SO were identified from the Singapore National Eye Centre uveitis database in the period between 1993 and 2003. The patients' case records were examined for a history of ocular trauma or surgery and subsequent development of bilateral or contralateral uveitis consistent with SO or histopathological evidence of SO in enucleated eyes. The medical records of these patients were reviewed for details of the inciting event, presentation, treatment, and visual acuity. Results A total of ten patients (six men and four women) were diagnosed with SO in the period of study. SO occurred after accidental trauma in three patients and following ocular surgery in seven. Vitreoretinal surgery was responsible for four of these cases, and diode laser cyclophotoablation for another two, whereas neodymium:yttrium–aluminium–garnet (Nd:YAG) laser cyclotherapy was the cause in the last patient. Overall, six of ten patients underwent at least one vitreoretinal procedure. Four of the patients had a final visual acuity of 6/15 or better, whereas five had a visual acuity of 6/30 or worse. Good final visual acuity appeared to be associated with early initiation of immunosuppressive therapy. Conclusion In this series, ocular surgery, especially vitreoretinal surgery, had overtaken non-surgical trauma as the major cause of SO. A good outcome was possible in most cases if an early diagnosis was made and immunosuppressive treatment started promptly.     

Clinical features, predisposing factors, and treatment outcomes of scleritis in the Korean population

Purpose

To evaluate the clinical features, associated factors, and treatment outcomes of scleritis in the Korean population.

Methods

Medical records were retrospectively reviewed for 94 eyes of 76 patients with scleritis. Clinical features of scleritis, including systemic disease, presence of microorganisms, serologic markers, history of previous ocular surgery, and use of immunosuppressants were investigated and compared amongst the subtypes of scleritis. Treatment outcomes were evaluated using best corrected visual acuity (BCVA) and time to scleritis remission.

Results

Nodular scleritis was the most common form observed, followed by necrotizing scleritis with inflammation, diffuse scleritis, and necrotizing scleritis without inflammation, respectively. A total of 16 of 76 patients (21.1%) had connective tissue diseases. Eleven cases (14.5%) had infectious scleritis, of which bacteria (54.5%) and fungi (45.5%) were the causative microorganisms. Thirty-three patients (43.4%) had previous ocular surgery, mostly pterygium excision. Notably, a history of pterygium excision was significantly associated with development of necrotizing and infectious scleritis (odds ratio [OR], 399 and 10.1; p < 0.001 and 0.002, respectively). In addition, patients with necrotizing scleritis were more likely to have infectious scleritis (OR, 11.7; p = 0.001). BCVA after treatment and time to remission also showed significant differences among the different scleritis subtypes. Systemic immunosuppression was required in addition to steroids for treating diffuse and necrotizing scleritis.

Conclusions

Careful taking of patient history including previous pterygium excision should be performed, especially in patients with necrotizing and infectious scleritis. In addition, evaluation of microbiological infection can be crucial for patients with necrotizing scleritis and history of pterygium excision.     

MALT-type B-cell lymphoma masquerading as scleritis or posterior uveitis

PURPOSE: Diagnostic and therapeutic management of masquerade syndromes associated with MALT-type lymphoma. PATIENTS AND METHOD: We report the cases of three patients referred for acute or chronic severe loss of visual acuity. All of them suffered from uveitis or scleritis resistant to corticoid treatment. Each one had posterior uveitis associated with retinochoroidal infiltration, anterior scleritis associated with uveal effusion syndrome, or bilateral pan-uveitis associated with serous retinal detachment. Two patients had medical records of systemic malignancies. They underwent an extensive work-up. Search for an infectious, immune or malignant disease was negative but orbital imaging showed a posterior scleral thickening in all cases. RESULTS: Diagnosis of mucosa-associated lymphoid tissue (MALT) ocular lymphoma was assessed in all cases after scleral biopsy. Immunohistochemical analysis showed CD20(+) and CD5(-) scleral lymphocyte infiltrates. The three patients underwent chemotherapy associated with radiotherapy. Lesions were stabilized in the first case, whereas six lines of visual acuity improvement was noted in the second one, and full recovery was achieved after treatment in the third case. DISCUSSION: Clinical manifestations of this ocular lesion seem to be multiple, masquerading as different types of posterior uveitis or scleritis. In the three cases, we did found other systemic locations of MALT-type lymphoma. Diagnosis was mainly based on pathological analysis. Fast visual recovery in two cases demonstrated the importance of an early diagnosis and a specific treatment. All cases of chronic and corticoid-resistant posterior uveitis require a specialized radiological evaluation followed, if necessary, by multiple orbital biopsies.     

Long-term progression, prognosis, and treatment of patients with recurrent ocular manifestations of Reiter's syndrome

PURPOSE: To investigate the spectrum of ocular involvement, to examine the clinical outcome, and to analyze the influence of treatment in patients with chronic ocular manifestations of Reiter's syndrome (RS) referred to a tertiary care ocular immunology service. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Twenty-five patients with RS evaluated at the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary from 1981 through 2001. METHODS: Charts of patients were reviewed and data on age, gender, follow-up time, ocular symptoms, extraocular involvement, ocular complications, therapy, and visual acuities were recorded. MAIN OUTCOME MEASURES: Visual acuity, ocular complications, disease progression, clinical outcome, and systemic treatment. RESULTS: Twenty-five patients (20 male and 5 female) diagnosed with RS, with a mean age at presentation to our service of 37 years, were studied. The mean follow-up was 48.5 months. Eighty-five percent of patients tested were positive for human leukocyte antigen B27. Sixty-four percent of patients had a positive family history. All patients had oligoarthritis and enthesitis, most commonly affecting the back (56%), Achilles tendon (52%), and sacroiliac joint (24%). Eighty percent had a history of infection, most frequently urethritis (68%). Forty-four percent had a history of mucocutaneous lesions. All patients demonstrated ocular involvement at the time of diagnosis (68% with unilateral and 32% with bilateral disease), 84% had evidence of uveitis, 3% had scleritis, 2% had conjunctivitis, and 1% had pars planitis and iridocyclitis. During follow-up, the ocular complications included conjunctivitis (96%), anterior uveitis (92%), posterior uveitis (64%), keratitis (64%), cataract (56%), intermediate uveitis (40%), scleritis (28%), cystoid macular edema (28%), papillitis (16%), and glaucoma (16%). Systemic treatment for ocular inflammation was initiated in all patients. Ninety-six percent were treated with nonsteroidal anti-inflammatory agents. Eighty-eight percent were treated with corticosteroids, 64% requiring systemic prednisone. Immunosuppressive therapy was initiated in 52% of patients, with all receiving methotrexate. Seven patients required more than one immunosuppressive agent. The mean initial visual acuity was 20/25 in the right eye and 20/30 in the left eye. The mean final visual acuity was 20/25 in the right eye and 20/25 in the left eye. CONCLUSIONS: Reiter's syndrome may be associated with chronic recurrent ocular inflammation. Systemic therapy (including immunosuppressive treatment) typically is required to control the ocular inflammation and to prevent progressive visual loss.     

Management of infectious scleritis after pterygium excision

PURPOSE: We sought to describe the clinical features, responsible pathogens, management, and prognosis of infectious scleritis after pterygium excision. METHODS: A retrospective study through review of medical records of patients diagnosed with infectious scleritis after pterygium excision over a 10-year period at our institution. RESULTS: A total of 16 cases of infectious scleritis after pterygium excision was identified. Among them, eight were associated with sclerokeratitis, and six had multifocal scleral nodules with subconjunctival abscesses. Culture results were positive in 15 (93.8%) cases. Pseudomonas was isolated in 13 (81.3%) patients, fungus in three (18.8%), and two had a mixed growth (12.5%). Based on the in vitro susceptibility test, four (31%) Pseudomonas isolates were resistant to gentamicin, whereas all isolates were sensitive to amikacin. During the course of treatment, eight cases were complicated by vitreous opacity, four developed glaucoma, four had serous retinal or choroidal detachment, and two had secondary cataract. Scleral infection recurred in two patients after cessation of therapy. Among the nine patients treated with medical therapy, two eyes were enucleated, whereas only two attained a visual acuity of > or =2/200 at the end of the follow-up period. On the other hand, seven patients had combined antibiotic therapy and surgical debridement. The number of surgical debridement ranged from one to three, with an average of 1.4. In this combined-treatment group, only one patient required enucleation, and five cases attained a visual acuity of > or =2/200. The duration of hospitalization for patients with combined treatment was 21.2+/-4.8 days compared with the 28.4+/-5.0 days for those with medical treatment alone (p = 0.035). CONCLUSION: Surgical debridement in combination with appropriate antimicrobial therapy shortens the course of treatment and improves the visual outcome of severe infectious scleritis after pterygium excision.     

Scleritis and Streptococcus pneumoniae

We retrospectively review our experience with four patients with Streptococcus pneumoniae scleritis. Two of the patients had been exposed to beta irradiation after pterygium removal 4 and 13 years previously. One patient had a 3-year history of chronic anterior nodular scleritis, and one patient had severe rheumatoid arthritis. All were treated with intensive i.v. and topical fortified antibiotics. In two of the cases, the infection was controlled and visual acuity returned to 20/30 and 20/60. In one patient, infectious scleritis progressed to endophthalmitis. This eye ultimately became phthisical and required enucleation because of chronic pain. In the remaining patient, infectious scleritis led to perforation, which required a corneal-scleral patch graft. This patient had a final visual acuity of counting fingers. An infectious etiology should be suspected in cases of necrotizing scleritis associated with a purulent discharge, and appropriate smears and cultures should be obtained. Infectious scleritis can be caused by streptococcal organisms. Appropriate topical and intravenous antibiotic treatment is effective in some cases.     

Posterior scleritis in children.

Posterior scleritis was diagnosed in four adolescent boys. These patients represented a distinct subgroup of patients with posterior scleritis that differed from the adult variant by gender, lack of systemic disease, and absence of the associated ocular findings often seen in the adult variant of the disorder. The four patients had diminished visual acuity, ocular pain, and exudative retinal detachments at initial examination. Fluorescein angiography demonstrated multiple pinpoint leaks at the level of the retinal pigment epithelium in three patients with late-phase patchy staining of a mass-like lesion in one patient. B-scan ultrasonography demonstrated choroidal and scleral thickening with increased acoustic density of the choroid in all patients. Systemic evaluation of these patients disclosed no underlying disease. Clinical signs and symptoms resolved in three of the patients after treatment with low-dose, orally administered corticosteroid or noncorticosteroid anti-inflammatory medication. High systemic doses of corticosteroid in combination with noncorticosteroid anti-inflammatory medication and local corticosteroid therapy was required to induce remission in one patient. All patients recovered good visual acuity.     

Ulcerative keratitis caused by Haemophilus influenzae

PURPOSE: To report the clinical course, treatments, antibiotic sensitivities, and visual outcomes for eyes with ulcerative keratitis caused by Haemophlilus influenzae. METHODS: The medical records of 10 patients with culture-proven H. influenzae-associated corneal ulcer in a tertiary referral center in a 5-year period (1998-2003) were retrospectively reviewed. RESULTS: The median age was 61 years (range, 2-83 years). The mean follow-up time was 9.4 months (range, 2-31 months). Risk factors such as previous surgeries (5), herpes simplex keratitis (2), leukoma adherens with calcification (1), and exposure keratitis (1) were identified in 9 patients. In vitro testing of the H. influenzae isolates showed that 6 of 10 were resistant to ampicillin; all were sensitive to amoxicillin/clavulanic acid, ceftriaxone, and cefuroxime. All cases responded well to medical antibiotic treatment. Final best spectacle-corrected visual acuity ranged from no light perception to 20/30. CONCLUSION: H. influenzae is a rare cause of corneal ulceration. Predisposing factors for infection are usually present. Accurate diagnosis and treatment may preserve ocular integrity and visual acuity.     

Clinical features and related factors of infectious necrotizing scleritis北大核心

目的探讨感染性坏死性巩膜炎的临床特点及相关因素,为临床预防及诊治提供参考。方法选择2017年5月至2022年5月在空军军医大学西京医院眼科诊治的感染性巩膜炎患者32例(32眼),对其中伴巩膜坏死的7例(7眼)感染性巩膜炎患者的病原学检查结果、临床表现和治疗转归等情况进行分析。结果7例感染性巩膜炎患者均为男性,其中有眼部手术史者5例、有眼外伤史者1例、无特殊病史者1例。7例患者均有局部或全身糖皮质激素类药物使用史。临床表现为前部巩膜感染性坏死,其中6例发生巩膜坏死、溃疡,1例为巩膜结节状脓肿。7例患者均有前房内炎症反应,并伴有高眼压、角膜溃疡、眼内炎、渗出性视网膜脱离等不同合并症。感染的原因为真菌2例、细菌4例和吸吮线虫1例。6例患者行巩膜坏死灶清创,其中5例还联合巩膜修补术,最终感染控制;1例眼部吸吮线虫感染的患者因拒绝手术仅通过药物治疗,在3个月随访时眼球已经萎缩。4例患者视力恢复良好,1例视力无变化,2例合并眼内炎的患者视力丧失。结论感染性坏死性巩膜炎是复杂难治疾病,多有明确的眼部感染病史,以巩膜溃疡坏死伴有分泌物为主要表现,当有结节状巩膜脓肿时应警惕可能是真菌感染,清创坏死灶是明确诊断和控制感染的有效手段。     

Orbital myositis in scleritis

AIMS: To investigate the association between scleritis and myositis. METHODS: Retrospective, non-comparative case series. Records and ultrasonograms were examined of 132 patients, with a diagnosis of episcleritis or scleritis, who attended the ophthalmology department at Leiden University Medical Center between 1997 and 2000. 103 were eligible for comprehensive examination. Medical records were evaluated. Ultrasonography was performed in all patients diagnosed with episcleritis or scleritis. Clinical features, precipitating factors, systemic associations, ocular complications, treatment, and outcome of each patient were assessed. RESULTS: Of the 103 patients, 27 (26.2%) had episcleritis and 76 (73.8%) had scleritis. Myositis was found to be present in 11 patients. It was present in 14.5% of all patients with scleritis and 30.5% of those in whom the posterior sclera was affected. The presence of the associated myositis did not worsen the visual prognosis and the presence of myositis was not associated with other systemic diseases. There were no cases of unilateral scleritis with bilateral orbital myositis. During an attack ocular complications were more common in patients with scleritis and myositis (64%) than in patients with scleritis alone (30.4%), indicating a more diffuse and potentially dangerous inflammation. There was no evidence that the inflammatory changes in the orbit had spread to involve the sclera, so it is assumed that the muscle changes are an extension of a generalised response to intense inflammation of the episclera and sclera. CONCLUSION: This study found a frequent association between myositis and scleritis. Prognosis for vision was not affected by coexistence of myositis.     

Cystoid macular edema associated with ocular hypotensive lipids

PURPOSE: To report angiographically documented cystoid macula edema associated with the use of each of the three newly available ocular hypotensive lipids: unoprostone, travaprost, and bimatoprost. DESIGN: Observational case series. METHODS: Retrospective review of three patients in a clinical practice who had uncontrolled glaucoma on maximal tolerable therapy except for an ocular hypotensive lipids. All three patients also had previous cataract and filtration surgery, and all had an absent or open posterior lens capsule. The patients were informed of the potential risks of cystoid macula edema associated with the use of an ocular hypotensive lipids versus the risks of repeat filtration surgery. RESULTS: An ocular hypotensive lipids was started in the affected eye in each patient, and the patient was instructed to check visual acuity everyday and report back any change in vision occurred. CONCLUSION: Decreased vision of at least two lines caused by angiographically confirmed cystoid macula edema was noted in each of three patients started, respectively, on unoprostone, travaprost, and bimatoprost. The visual acuity returned to baseline, and the cystoid macula edema was angiographically resolved after discontinuation of the ocular hypotensive lipids and the initiation of a topical steroid and non-steroidal anti-inflammatory eyedrops. Until a causal relationship between cystoid macula edema and ocular hypotensive lipids is proved or disproved, caution in their use in high-risk eyes would be prudent.     

Tumor necrosis factor alpha blockade with infliximab for refractory uveitis and scleritis

OBJECTIVE: To assess the efficacy and safety of the anti-tumor necrosis factor alpha agent infliximab in treatment-resistant uveitis and scleritis. DESIGN: Retrospective, noncomparative interventional case series. PARTICIPANTS: Seven patients with noninfectious ocular inflammatory disease that was refractory to alternative immunosuppression. These included one patient with idiopathic retinal vasculitis and panuveitis, one patient with intermediate uveitis, one patient with chronic juvenile anterior uveitis, three patients with scleritis, and one patient with scleritis and peripheral ulcerative keratitis. Four patients had an underlying systemic disease that was in remission in three cases. INTERVENTION: Infusions of infliximab, 200 mg, were given at 4-week to 8-week intervals, depending on the clinical response. MAIN OUTCOME MEASURES: Clinical response, including symptoms, visual acuity, degree of scleral vascular engorgement, corneal thinning, anterior chamber activity, and posterior segment inflammation, reduction in concomitant immunosuppression, and adverse effects. RESULTS: The mean patient age was 47 years (range, 24-78), and four patients were female. The mean number of infliximab infusions was seven (range, 2-19), and the mean follow-up period was 12 months (range, 4-22 months). Six patients experienced a clinical improvement, with five achieving remission and significant reduction in immunosuppression. One patient showed an initial response but developed a delayed hypersensitivity response that precluded further treatment. No other adverse effects occurred. CONCLUSIONS: Infliximab seems to be an effective and safe treatment for noninfectious uveitis and scleritis and may be indicated as rescue therapy for relapses of ocular inflammation or as maintenance therapy when conventional immunosuppression has failed. Further investigation of infliximab for treatment-resistant scleritis and uveitis is warranted.     

Scleritis associated with sarcoidosis

PURPOSE: To review scleritis cases associated with sarcoidosis and to evaluate clinical features, medical treatment, and clinical course. METHODS: Two cases of diffuse anterior scleritis and a nodular scleritis case associated with systemic sarcoidosis were evaluated. Scleritis was the first manifestation of sarcoidosis in two of the patients and the diagnosis of sarcoidosis was confirmed with a conjunctival biopsy. The third patient had the diagnosis of systemic sarcoidosis when she developed scleritis. RESULTS: Based on the clinical and histological appearance, two patients presented with bilateral diffuse anterior scleritis and the third patient with an anterior nodular scleritis. One patient already had the diagnosis of systemic sarcoidosis at presentation, while ocular findings led to the diagnosis in the other two cases. Conjunctiva or skin biopsies revealed features compatible with the diagnosis of sarcoidosis. Scleritis attacks recurred in two patients. All patients responded well to systemic corticosteroid (prednisone) therapy. CONCLUSIONS: Scleritis associated with sarcoidosis has rarely been described and it may be the presenting sign of systemic sarcoidosis.     

Posterior scleritis: clinical features, systemic associations, and outcome in a large series of patients

OBJECTIVE: To document the clinical features, systemic associations, and visual outcome in a large number of patients with posterior scleritis. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: There were 137 patient records showing patients with a diagnosis of posterior scleritis who were attending or had attended the scleritis clinic at Moorfields Eye Hospital between 1974 and 1996. Ninety-nine records were suitable for detailed analysis. METHODS: The medical records and B-mode ultrasound examinations were reviewed. MAIN OUTCOME MEASURES: The clinical features, systemic associations, treatment, and outcome of each patient were determined. RESULTS: Posterior scleritis occurred at all ages. The mean age at onset was 49.3 years. Posterior scleritis began before age 40 in 30% of patients and was twice as common in women as in men. The B-mode ultrasound examination showed diffuse and nodular changes in the posterior sclera. Necrotizing posterior scleritis was not identified. Twenty-nine percent of patients had an associated systemic disease that included systemic vasculidites, autoimmune diseases, and lymphoma. Such patients more commonly had nodular changes on B-mode ultrasound examination. Early treatment controlled posterior scleral inflammation and limited visual loss. Thirty-one percent of patients lost two or more lines of vision. Statistical analysis revealed that patients older than age 50 had an increased risk of having an associated systemic disease and were more likely to experience visual loss. Patients with associated systemic disease required more aggressive immunosuppressive therapy and more frequently had accompanying anterior scleritis. There was no association between unilateral, bilateral, or recurrent disease and the presence of systemic disease or visual loss from posterior scleritis. CONCLUSIONS: The B-mode ultrasound examination reveals that posterior scleritis occurs far more often than previously thought and can lead to rapid and permanent visual loss. All patients with posterior scleritis must be assumed to be at risk of visual loss. Forty percent of patients had no anterior scleral inflammation, and 9% had no detectable physical signs. All patients need to be investigated for an associated systemic disease and all require early treatment to minimize loss of vision.     

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.     

Biologic Response Modifier Therapy for Psoriatic Ocular Inflammatory Disease

Purpose: To evaluate the efficacy and safety of biologic response modifiers (BRMs) in the treatment of patients with psoriatic ocular inflammatory disease. Methods: The records of 8 patients diagnosed with psoriatic ocular inflammatory disease who received adalimumab or infliximab were reviewed. Main outcome measures were control of intraocular inflammation, visual acuities, and adverse effects of therapy. Results: The mean patient age was 53 ± 15 years. Three patients had psoriatic panuveitis, 3 had psoriatic scleritis, and 2 patients had psoriatic anterior uveitis. The ocular inflammatory disease was bilateral in 7 patients. Four patients received adalimumab, and 4 received infliximab. Average time of therapy was 6.1 ± 4.7 months. Six patients were treated concurrently with methotrexate. With respect to visual acuity, 2 patients demonstrated improvement, 2 patients demonstrated deterioration, and 4 patients remained stable. Seven patients achieved remission of their ocular inflammation. Conclusions: BMRs can be a useful adjunctive therapy for psoriatic ocular inflammatory disease.