Posterior Scleritis in a Patient with Psoriasis Masquerading as Acute Angle Closure Glaucoma

Abstract

Posterior scleritis is a relatively uncommon form of scleral inflammation of the posterior segment of the eye. Clinical manifestations include ocular pain, headache, pain with ocular movements, and loss of vision. A rare presentation of the disease is acute angle closure crisis (AACC) with elevated intraocular pressure (IOP) secondary to anterior displacement of the ciliary body. Various systemic diseases have been described to co-exist with posterior scleritis; however, psoriasis has not been associated with posterior scleritis. Here, we present a case of posterior scleritis which initially presented as AACC in a patient with pre-existing psoriasis. A 50-year-old male with a history of psoriasis under treatment presented to the emergency department with intense sudden ocular pain and loss of vision on the left eye as well as headache and nausea. A thorough medical and ocular history was taken, and a detailed examination of the anterior and posterior segment was completed including visual acuity and IOP. Initial diagnosis of AACC was made, and appropriate actions were taken with partial resolution of his symptoms. However, upon further work-up including ultrasound (B-scan) of the left eye a final diagnosis of posterior scleritis was made. The patient was treated with steroids and nonsteroidal anti-inflammatory drugs which dramatically improved his condition. Photographic evidence of initial presentation and post-treatment condition was obtained and presented in this report. Posterior scleritis is a potentially vision-threatening condition which is usually challenging to diagnose. In this report, we highlight the challenges one might come into when dealing with different manifestations of the same disease, increasing awareness. This case of posterior scleritis presenting as AACC in a patient with a history of psoriasis enhances what we already know from the literature as well as provides some new insights in the clinical manifestations of posterior scleritis in the setting of psoriasis without arthritis.

Keywords: Angle closure glaucoma; Posterior scleritis; Psoriasis.

Fig. 1

Initial presentation with mid dilated pupil and shallow anterior chamber. Note the unexplained inferior conjunctival chemosis (blue arrows) that is unusual for primary angle closure attack.

Fig. 2

Photo of the first post-iridectomy day, revealing a patent iridectomy and normal pupil but worsening of the conjunctival chemosis.

Fig. 3

B-scan of the patient demonstrating thickened posterior sclera forming the characteristic “T-sign” (dashed line).

Fig. 4

Axial T2 with fat suppression MRI, revealing thickening with enhancement involving outer and inner aspect of left posterior sclera (black arrows).

Fig. 5

a, bFinal photos of the patient with complete resolution of conjunctival edema, patent iridectomy (a), and deep anterior chamber (b).