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CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 30-32

Posterior scleritis: Cause of diagnostic confusion


University Hospital Center Mohammed VI, Oujda, Morocco

Date of Submission17-May-2020
Date of Acceptance15-Jun-2020
Date of Web Publication27-Aug-2020

Correspondence Address:
Dr. Abdi Rhizlane
Kenzi II Residency, R21 0 D hay al Andalouss, Oujda
Morocco
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DOI: 10.4103/sjopthal.sjopthal_9_20

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  Abstract 

Posterior scleritis can occur in isolation or concomitantly with anterior scleritis. Some investigators include posterior scleritis as an anterior variant of inflammatory pseudotumor. The main clinical manifestations are pain, exophthalmia, decreased visual acuity, and occasionally, restricted ocular motility. Choroidal folds, exudative retinal detachment, papillary edema, and angle-closure glaucoma secondary to choroidal thickening may be observed. The diagnosis can be missed in the absence of associated anterior scleritis. Demonstration of thickened posterior sclera by echography, computed tomographic scan, or magnetic resonance imaging may be helpful in establishing the diagnosis. Often, no related systemic disease can be found in patients with posterior scleritis.

Keywords: Echography, computed tomographic scan, scleritis


How to cite this article:
Rhizlane A, Siham C, Asmae M, Rachid S. Posterior scleritis: Cause of diagnostic confusion. Sudanese J Ophthalmol 2020;12:30-2

How to cite this URL:
Rhizlane A, Siham C, Asmae M, Rachid S. Posterior scleritis: Cause of diagnostic confusion. Sudanese J Ophthalmol [serial online] 2020 [cited 2020 Sep 26];12:30-2. Available from: http://www.sjopthal.net/text.asp?2020/12/1/30/293638


  Introduction Top


Posterior scleritis is one of the most often misdiagnosed pathologies in ophthalmology.[1] It is an affection often unknown, because of the inaccessibility of the sclera posterior to the direct examination. It is characterized by clinical polymorphism and confusing symptomatology with several inflammatory and noninflammatory eye diseases.[2]

Early diagnosis is important because a treatment started early often leads to complete resolution with excellent visual recovery.

Ultrasonography has been found very useful in the diagnosis of posterior scleritis.[3]

Computed tomography (CT)[4] and angiography[1] can also be used as auxiliary tests. We report the case of posterior scleritis initially misdiagnosed clinically, and then, a clinical and paraclinical examination established the diagnosis.


  Clinical Case Top


A 23-year-old patient admitted initially in the context of cellulite of the left eye [Figure 1]. The story of his illness goes back 3 days before her hospitalization by the sudden appearance of a painful inflammatory exophthalmia with visual fog. The patient received a triantibiotherapy without significant improvement and then was referred to our formation for care. Ophtalmological examinationon the left eye showed:[Figure 1]a, [Figure 1]b
Figure 1: (a) Inflammatory exophthalmia with chemosis (b) inflamatory chemosis

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visual acuity at 2/10, p5; eyelid edema; exophtalmia and ophtalmoplegia.

Fundus revealed Stage I papillary edema and choroidal folds [Figure 2]. We performed a fluorescein angiography which showed retention of the contrast product in the papilla [Figure 3]. We completed with orbitocerebral CT that revealed scleral thickening [Figure 4]. Ultrasound B confirmed CT data showing localized scleral thickening in the posterior pole of the left eye [Figure 5].
Figure 2: Fundus: Choroidal folds + papillary hyperhemia

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Figure 3: Angiography: Retention of the contrast product in papilla

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Figure 4: Orbitocerebral computed tomography: Scleral thickening and of the periorbital muscle wall

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Figure 5: Ultrasound B: Localized scleral thickening in the posterior pole of the left eye

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The diagnosis of posterior scleritis was retained, and an etiological assessment was requested (negative income). A bolus of methylprednisolone was instituted at a rate of 10 mg/kg/day for 3 days with relay by prednisone per os at a rate of 1 mg/kg/day. The evolution was spectacular with regression of pain, improvement of visual acuity to 10/10, and regression of papillary edema and macular folds on the fundus [Figure 6] and [Figure 7].
Figure 6: Regression of palpebral edema and exophthalmia after treatment

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Figure 7: Regression of papillary edema after treatment

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  Discussion Top


Posterior scleritis is a rare and often unrecognized, that's why, it can simulate many infections, including intraocular tumors and orbital or cerebral pathology.

Ocular echography is the key for diagnosis of posterior scleritis.[5]

Oculo-orbital CT is useful for confirming the diagnosis in doubtful cases and differentiating an inflammatory disease from an infiltrative process.[4]

Posterior scleritis is idiopathic in 75% of cases, and in remaining 25%, it is associated with systemic diseases.[6]

The corticosteroid should be the first line of treatment in this entity. The disease usually shows a good response to systemic anti-inflammatory therapy.[6]


  Conclusion Top


Posterior scleritis is often difficult to diagnose. We have to think about it next to any inflammatory and painful ocular symptomatology, which does not prove its origin. It can simulate many diagnoses like that of cellulite.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot bechrological order guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Benson WE, Shields JA, Tasman W, Crandall AS. Posterior scleritis. A cause of diagnostic confusion. Arch Ophthalmol 1979;97:1482-6.  Back to cited text no. 1
    
2.
Benson WE. Posterior scleritis. Surv Ophthalmol 1988;32:297-316.  Back to cited text no. 2
    
3.
Munk P, Nicolle D, Downey D, Vellet AD, McKeown M. Posterior scleritis: Ultrasound and clinical findings. Can J Ophthalmol 1993;28:177-80.  Back to cited text no. 3
    
4.
Chaques VJ, Lam S, Tessler HH, Mafee ME Computed tomography and magnetic resonance imaging in the diagnosis of posterior scleritis. Ann Ophthalmol 1993;25:89-94.  Back to cited text no. 4
    
5.
Cantalloube A, Tuil C, Tuil E. Ultrasound aspects of posterior scleritis. Ophthalmology 1998;2: 80-3.  Back to cited text no. 5
    
6.
Biswas J, Mittal S, Ganesh SK, Shetty NS, Gopal L. Posterior scleritis: Clinical profile and imaging characteristics. Indian J Ophthalmol 1998;46:195-202.  Back to cited text no. 6
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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