Bilateral posterior scleritis presenting as acute primary angle closure: A case report

Abstract

Background: Scleritis is a rare disease and the incidence of bilateral posterior scleritis is even rarer. Unfortunately, misdiagnosis of the latter is common due to its insidious onset, atypical symptoms, and varied manifestations. We report here a case of bilateral posterior scleritis that presented with acute eye pain and intraocular hypertension, and was initially misdiagnosed as acute primary angle closure. Expanding the literature on such cases will not only increase physicians' awareness but also help to improve accurate diagnosis.

Case summary: A 53-year-old man was referred to our hospital to address a 4-d history of bilateral acute eye pain, headache, and loss of vision, after initial presentation to a local hospital 3 d prior. Our initial examination revealed bilateral cornea edema accompanied by a shallow anterior chamber and visual acuity reduction, with left-eye amblyopia (> 30 years). There was bilateral hypertension (by intraocular pressure: 28 mmHg in right, 34 mmHg in left) and normal fundi. Accordingly, acute primary angle closure was diagnosed. Miotics and ocular hypotensive drugs were prescribed, but the symptoms continued to worsen over the 3-d treatment course. Further imaging examinations (i.e., anterior segment photography and ultrasonography) indicated a diagnosis of bilateral posterior scleritis. Methylprednisolone, topical atropine, and steroid eye drops were prescribed along with intraocular pressure-lowering agents. Subsequent optical coherence tomography (OCT) showed gradual improvements in subretinal fluid under the sensory retina, thickened sclera, and ciliary body detachment.

Conclusion: Bilateral posterior scleritis can lead to secondary acute angle closure. Diagnosis requires ophthalmic accessory examinations (i.e., ultrasound biomicroscopy, B-scan, and OCT).

Keywords: Acute primary angle closure; B-scan; Case report; Differential diagnosis; Optical coherence tomography; Posterior scleritis.

Figure 1

Anterior segment photography before treatment. A quite shallow anterior chamber was present in both eyes and accompanied by mild cornea edema. The pupils were 5 mm, round, and symmetrical to each other. The lenses were transparent without dislocation. A: Right eye; B: Left eye.

Figure 2

Ultrasound biomicroscopic examination before treatment. The anterior chamber depths were 1.9 mm for the right eye and 1.8 mm for the left eye. Cyclodialysis, pronated ciliary process, and totally closed anterior chamber angle were present. A: Right eye; B: Left eye.

Figure 3

Optical coherence tomography examination before treatment. A: Retinal pigment epithelial folds were found in the right eye; B: Optic disc edema and multiple serous retinal detachments were found in the left eye.

Figure 4

B-scan ultrasonography examination before treatment. Thickening of the posterior walls was present in both eyes, as was fluid under Tenon’s capsule.

Figure 5

Optical coherence tomography examination after treatment. Retinal pigment epithelial folds and serous detachment were found to have gradually resolved after 1 wk of treatment. A: Right eye; B: Left eye.

Figure 6

B-scan ultrasonography examination after treatment. Resolution of cyclodialysis and the thinning of posterior walls were found.

Figure 7

Slit-lamp examination after treatment. Deepening of the anterior chamber and dilation of the pupil upon atropine sulfate eye ointment application were found.