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   Table of Contents      
BRIEF REPORT
Year : 2006  |  Volume : 54  |  Issue : 2  |  Page : 120-122

Giant nodular posterior scleritis simulating choroidal melanoma


Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, 1, Anna Nagar, Madurai - 625 020, Tamil Nadu, India

Correspondence Address:
Dhananjay Shukla
Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, 1, Anna Nagar, Madurai - 625 020, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.25835

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  Abstract 

A 45-year-old woman, complaining of sudden visual loss in the right eye (best-corrected visual acuity: 17/200), was suspected of having a malignant melanoma of the choroid. Fundus examination revealed a massive pale-colored subretinal mass temporal to the fovea, with adjoining choroidal folds and exudative retinal detachment. Ultrasonography was suggestive of posterior scleritis. Systemic evaluation was unremarkable. The patient was treated with high-dose systemic corticosteroids. The mass lesion resolved completely, with visual recovery to 20/20. Posterior scleritis should be suspected when evaluating subretinal mass-lesions, even when large and without overt inflammation. Early treatment may improve the visual prognosis and avoid misdirected management, including enucleation.

Keywords: Noduler posterior scleritis, malignant melanoma.


How to cite this article:
Shukla D, Kim R. Giant nodular posterior scleritis simulating choroidal melanoma. Indian J Ophthalmol 2006;54:120-2

How to cite this URL:
Shukla D, Kim R. Giant nodular posterior scleritis simulating choroidal melanoma. Indian J Ophthalmol [serial online] 2006 [cited 2019 Nov 15];54:120-2. Available from: http://www.ijo.in/text.asp?2006/54/2/120/25835

Posterior scleritis is a potentially blinding ocular disorder, often misdiagnosed due to its low incidence and varied clinical presentation, leading to delayed or wrong treatment.[1],[2] Nodular posterior scleritis is especially notorious for mimicking choroidal pathologies like granuloma, hemangioma and most importantly, amelanotic choroidal melanoma, which may lead to an unwarranted enucleation.[2],[3],[4],[5] We present a case of isolated giant nodular posterior scleritis, initially diagnosed as a choroidal melanoma; but successfully treated by systemic steroids, with complete resolution and visual recovery.


  Case Report Top


A healthy 45-year-old lady was referred for an acute loss of vision in the right eye, with a diagnosis of choroidal melanoma. She did not give any history of preceding or concomitant systemic or ocular disease, except mild pain in the right eye. Best-corrected visual acuity was 17/200 in the right eye and 20/20 in the left eye. Anterior segment examination was unremarkable in both eyes. Right fundus examination revealed a massive cream-colored lesion, temporal to fovea, with an exudative detachment involving the fovea and extending inferiorly. Folds were visible in the internal limiting membrane and choroid. [Figure - 1]a There were no vitreous cells or flare. Posterior segment of the left eye was normal. Fluorescein angiography (FA) of the right eye showed a late staining of the mass lesion; without the features of "double circulation." B-scan ultrasonography revealed a prominent dome-shaped mass (9.8 mm x 10.3 mm x 4.5 mm), with moderate acoustic reflectivity at the sclerochoroidal level and with fluid in subTenon's space [Figure - 1]b. General physical examination and abdominal ultrasound were unremarkable. Laboratory and ancillary investigations including ESR, a complete blood cell count, PPD skin test, chest X-ray, urinalysis, VDRL, rheumatoid factor and antinuclear antibody were normal. The patient was treated with intravenous methyl prednisolone, 15 mg/kg/day for 3 days. The mass reduced in size, with near-total disappearance of the detachment and visual improvement to 20/60 [Figure - 1]c. She was discharged on oral Prednisolone at 1 mg/kg/day, starting with 50 mg /day, tapered to 40 mg and 30 mg, at 10-day intervals. The patient returned a month later, with complete clinical and sonographic resolution of the mass lesion; vision in the right eye had improved to 20/20 [Figure - 1]d. Steroids were tapered off in reducing doses of 20, 10 and 5 mg at 10-day intervals; she was off steroids after 2 months. Last follow-up at 15 months showed stable ocular and systemic status.


  Discussion Top


A case of giant nodular posterior scleritis, suspected to be amelanotic choroidal melanoma, was diagnosed using B-scan ultrasonography; and successfully treated with intravenous and oral corticosteroids. No systemic associations were apparent.

Posterior scleritis has been reported to mimic a variety of ocular inflammatory and neoplastic conditions.[2],[3],[4],[5] Associated anterior scleritis, eventually seen in up to 60% of cases, helps in diagnosis.[6] Nodular posterior scleritis, especially when very large and associated with minimal inflammation, may closely resemble choroidal melanoma, as described in 3 reports.[3],[4],[5] In spite of ultrasonic confirmation, Finger and colleagues could not rule out melanoma; and offered the options of observation, radiation or enucleation to the patient. The eye was subsequently enucleated and the diagnosis of scleritis retrospectively confirmed by histopathological examination.[4] Demirci and associates performed a trephine biopsy for the same purpose, without any adverse effects on the ocular inflammation.[3] Arevalo et al used magnetic resonance imaging (MRI) to support the diagnosis. They also used Indocyanine green angiography (ICGA); but choroidal folds were their only positive finding,[5] which can easily be seen clinically, as well as on FA. A recent evidence-based update on the use of ICGA did not recommend it for anterior/posterior scleritis, as it added no useful diagnostic information; but conceded its possible value in monitoring the effect of treatment.[7] In addition, computed tomography (CT) scan has also been employed as a diagnostic adjunct.[2],[6] However, short of invasive histological confirmation, B-scan ultrasonography is the key investigation, which provides the strongest diagnostic evidence in posterior scleritis. MRI and CT apparently have no advantage over this inexpensive investigation,[1],[2],[6] even though they have been used by investigators as additional diagnostic tools. They may be reserved for cases where ultrasound images are unsatisfactory or inconclusive.[1],[6]

Our patient was suspected to have scleritis on the basis of a complaint of ocular pain and the clinical finding of choroidal folds, both of which pointed against melanoma or hemangioma. However, she had a creamy-yellow opaque mass, without the other reported clinical clues of posterior scleritis: lesion color matching the background choroid, visibility of choroidal vasculature and positive trans-illumination.[3],[5] However, B-scan ultrasound was not suggestive of possible choroidal lesions: melanoma, granuloma or hemangioma. FA was supportive, but not definitive for diagnosis, as reported by others.[1],[6] Our patient could not afford an MRI; and after rapid improvement on a trial of corticosteroids, it was not deemed necessary.

We successfully treated a case of giant nodular posterior scleritis, using systemic steroids. Steroids are however not always helpful.[6] Arevalo et al reported inefficacy of steroids in their case. In view of the good vision and mild symptoms, additional immunosuppressive agents were not used.[5] Demirci et al reported a 12-year follow-up of an asymptomatic case without any treatment.[3] Biswas and colleagues reported a case of massive nodular posterior scleritis in their series, which improved from a vision of Counting fingers at 1 metre, to 20/60 on oral steroids at 7.5 months, with persisting choroidal folds.[2] McCluskey and Wakefield favor an aggressive approach to severe cases of scleritis; and have reported the safety and efficacy of pulsed therapy with intravenous methyl prednisolone.[8] Patients with significant visual loss or lesions near the posterior pole require more aggressive therapy.[1],[6],[8] In spite of such treatment, a third of patients with posterior scleritis suffer further loss of vision.[6] We obtained a rapid and complete meltdown of a giant-sized nodule of posterior scleritis, with visual recovery from 17/200 to 20/20 on intravenous, followed by oral regimen of corticosteroids. We recommend a higher level of suspicion during evaluation of posterior segment mass lesions, to detect this under-recognized but eminently treatable condition.

 
  References Top

1.
Watson PG, Hazelman BL, Pavesio C, Green WR. The Sclera and Systemic Disorders . 2nd ed. Butterworth-Heinmann: Edinburgh; 2004. p. 59-89.  Back to cited text no. 1
    
2.
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. 2
[PUBMED]    
3.
Demirci H, Shields CL, Honavar SG, Shields JA, Bardenstein DS. Long-term follow-up of giant nodular posterior scleritis simulating choroidal melanoma. Arch Ophthalmol 2000;118:1290-2.   Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.
Finger PT, Perry HD, Packer S, Erdey RA, Weisman GD, Sibony PA. Posterior scleritis as an intraocular tumour. Br J Ophthalmol 1990;74:121-2.   Back to cited text no. 4
[PUBMED]    
5.
Arevalo JF, Shields CL, Shields JA. Giant nodular posterior scleritis simulating choroidal melanoma and birdshot retinochoroidopathy. Ophthal Surg Las Imag 2003;34:403-5.  Back to cited text no. 5
[PUBMED]    
6.
McCluskey PJ, Watson PG, Lightman S, Haybittle J, Restori M, Branley M. Posterior scleritis: Clinical features, systemic associations and outcome in a large series of patients. Ophthalmology 1999;106:2380-6.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.
Stanga PE, Lim JI, Hamilton P. Indocyanine green angiography in chorioretinal diseases: Indications and interpretation: An evidence-based update. Ophthalmology 2003;110:15-21.   Back to cited text no. 7
[PUBMED]    
8.
McCluskey P, Wakefield D. Intravenous pulse methylprednisolone in scleritis. Arch Ophthalmol 1987;105:793-7.  Back to cited text no. 8
[PUBMED]    


    Figures

  [Figure - 1]


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