Nodular posterior scleritis mimicking choroidal metastasis: a report of two cases

Abstract

Posterior scleritis is a rare underdiagnosed condition that can potentially cause blindness. Its varied presentations lead to delayed or incorrect treatment. We present here the cases of two patients with nodular posterior scleritis mimicking a choroidal metastasis. Two female patients presented with a sudden unilateral visual loss associated with ocular pain. Fundus examination revealed temporomacular choroidal masses with exudative detachments that, due to angiographic presentation, were suggestive of choroidal metastasis. Systemic examinations were unremarkable. In the two cases, a local or general anti-inflammatory treatment led to the complete recovery of the lesions, which were, thus, considered nodular posterior scleritis. The diagnosis of nodular posterior scleritis has to be evoked in all patients presenting with a choroidal mass in fundus examination. It represents the principal curable differential diagnosis of malignant choroidal tumor.

Keywords: blindness; choroidal mass; choroidal tumor; ocular pain; posterior scleritis; visual loss.

Figure 1

Case 1. Fundus photograph. Massive yellowish lesion, temporal to fovea, with an exudative detachment involving the fovea and choroidal folds.

Figure 2

Case 1. Fluorescein angiography sequence. Pronounced choroidal folds and early hyperfluorescence, with leakage and some pin points.

Figure 3

Case 1. B-scan ultrasonography. Thickening of the ocular coats associated with subretinal fluid adjacent to the mass (A). There is no orbital shadowing. Mass was prominent in the vitreous cavity and measured 11 mm × 4.6 mm (B).

Figure 4

Case 2. Fundus photograph. Unique and massive orange-yellow protruding lesion temporal to macula with an exudative detachment involving the fovea and extending inferiorly.

Figure 5

Case 2. Fluorescein angiography sequence. Progressive and heterogeneous hyperfluorescence, with pin points temporal to the mass.

Figure 6

Case 2. Optical coherence tomography. Serous retinal detachment and elevation of the retina depending on a choroidal mass.

Figure 7

Case 2. Brain magnetic resonance imaging in FLAIR (fluid-attenuated inversion recovery sequence) (A), T1 weighted with gadolinium (B) and STIR (short-tau inversion recovery sequence) (C). The nodular lesion appears in well limited hypersignal in the right eye, with no gadolinium enhancement. The hypersignal is most prominent in the STIR sequence.

Figure 8

Case 2. Fluorescein angiography 2 weeks after the first examination. Punctuated hyperfluorescence in place of the initial lesion, suggesting retinal pigment epithelium atrophy.