Clinical features and long-term treatment outcome of posterior scleritis

Abstract

Background: To analyze the clinical characteristics and long-term treatment outcomes of patients with posterior scleritis.

Methods: This retrospective, observational case series analyzed medical records of 14 patients diagnosed with infectious or non-infectious posterior scleritis between May 2005 and March 2020 at Severance Hospital and Gangnam Severance Hospital.

Results: A total of 12 patients with non-infectious and two with infectious posterior scleritis were treated. Conjunctival injection (85.7%) was the most common symptom, followed by pain on eyeball movement (57.1%), and decreased visual acuity (42.9%). Anterior uveitis (64.3%) was the most common associated clinical finding. In five eyes (35.7%), immunosuppressive agents were administered in addition to corticosteroids to control the inflammation. Recurrence was noted in three eyes (21.4%), all of them showing non-infectious scleritis. The final visual acuity of the patients did not show significant change compared to that at the first visit (P=0.878).

Conclusions: Most posterior scleritis patients were of non-infectious type and some needed additional immunosuppressive treatment. In patients with a history of ocular surgery or trauma, especially with the presence of pus-containing nodules, infectious posterior scleritis should always be considered. Since impaired vision does not improve significantly after treatment of posterior scleritis, prompt diagnosis and aggressive treatment are recommended.

Keywords: Posterior scleritis; infectious scleritis; uveitis.

Figure 1

A case of non-infectious posterior scleritis. A 57-year-old woman visited our clinic, complaining of lowered vision, pain, and hyperemia in the left eye for 3 days. The patient had a history of sero-negative spondyloarthropathy and was positive for HLA-B27. At that time, her visual acuity was 20/1,000 and intraocular pressure was 13 mmHg. (A) Severe conjunctival injection, corneal edema with folding of the Descemet’s membrane, and inflammatory cells (4+) in the anterior chamber are observed. Synechia with dysmorphic pupil, and multiple iridial pigments on the lens surface are present. (B) Funduscopic examination revealed vitreous haziness. The optic disc alone is visible, though faintly. (C) OCT revealed absence of macular edema. Because of vitreous haziness, OCT signals are reduced. (D) B-scan ultrasonography revealed an increase in the choroid and scleral thickness. The patient was administered topical steroids eight times a day, topical cycloplegic three times a day, and oral prednisolone 60 mg daily. After 1 week, the signs and symptoms improved. The dose of prednisolone was tapered by 10 mg each week over 6 weeks, and that topical steroids was tapered to end the treatment after 6 weeks. After 2 months of treatment, the visual acuity of the left eye improved to 20/25, and conjunctival injection disappeared. The cornea was clear, and there were no inflammatory cells in the anterior chamber. (E) Funduscopic examination revealed absence of vitreous haziness or abnormal findings. (F) OCT demonstrated absence of any definite structural abnormality. OCT, optical coherence tomography.

Figure 2

A case of infectious posterior scleritis. An 80-year-old woman presented with a reduction in visual acuity for 1 month. She had been operated for cataract 10 years ago. At the first visit, visual acuity was ability to count fingers, and intraocular pressure was 4 mmHg. Cells were present in the anterior chamber (3+). (A) Severe hyperemia of the conjunctiva, a yellowish nodular protruding mass around the limbus, and focal scleral thinning are seen (arrow). (B) Funduscopic examination revealed choroidal folding. (C) B-scan ultrasonography confirmed choroidal detachment. (D) Left: T1-weighted fat suppression magnetic resonance imaging revealed high signal intensity of the scleral wall and adjacent peri-ocular tissue, and high signal intensity in front of the lateral rectus muscle; right: coronal plane showed high signal intensity of the scleral wall and the maxillary sinus wall. (E) OCT demonstrated choroidal folding, choroidal effusion, and subretinal fluid. Third generation cephalosporin and ciprofloxacin were administered intravenously for 5 days, and then orally for another week. Five months after the patient’s first visit, visual acuity improved to 20/133, and intraocular pressure was 8 mmHg. (F) Choroidal folding disappeared and the fundus appeared stable. (G) OCT reveals absence of subretinal fluid. OCT, optical coherence tomography.