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   Table of Contents      
CASE REPORT
Year : 2019  |  Volume : 67  |  Issue : 8  |  Page : 1362-1365

Tubercular posterior scleritis: A case report and review of literature


Department of Uvea, Medical and Vision Research Foundations, Sankara Nethralaya, Tamil Nadu, India

Date of Submission22-Nov-2018
Date of Acceptance24-Mar-2019
Date of Web Publication22-Jul-2019

Correspondence Address:
Dr. Parthopratim Dutta Majumder
Department of Uvea, Sankara Nethralaya, 18, College Road, Nungambakkam, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1942_18

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  Abstract 


A 47-year-old female presented with optic disc oedema, peripapillary subretinal fluid and scattered areas of choroiditis. Her ultrasound B-scan showed sclerochoroidal thickening with widening of sub-Tenon space. Subsequent investigations revealed a positive Mantoux test and high-resolution computed tomography of the chest was suggestive of pulmonary involvement. She responded well to antitubercular treatment and systemic corticosteroid. A review of the literature was conducted to identify additional reports on similar cases and discussed. A high index of suspicion and appropriate laboratory work-up can aid in the diagnosis of tuberculous posterior scleritis.

Keywords: Choroiditis, posterior scleritis, scleritis, tuberculosis


How to cite this article:
Agarwal AM, Dutta Majumder P. Tubercular posterior scleritis: A case report and review of literature. Indian J Ophthalmol 2019;67:1362-5

How to cite this URL:
Agarwal AM, Dutta Majumder P. Tubercular posterior scleritis: A case report and review of literature. Indian J Ophthalmol [serial online] 2019 [cited 2019 Aug 25];67:1362-5. Available from: http://www.ijo.in/text.asp?2019/67/8/1362/263125



Posterior scleritis is an uncommon and relatively unrecognized form of scleral inflammation. It has been reported to account for 2%-12% of all cases of scleritis.[1] Posterior scleritis is known for its protean fundus pictures: choroidal folds or retinal striae, optic nerve head edema, circumscribed mass and exudative retinal detachment.[1] Scleral inflammation can be the initial manifestation of an unexpected systemic disease. Posterior scleritis is associated with a systemic disorder in as many as in 30% of patients[1] and rarely has been described as a result of infectious process. However, infection of the sclera following the spread of a local or systemic infectious disease process is not uncommon.[2],[3],[4],[5] It is important to rule out infectious etiology in scleritis as infectious scleritis may be clinically identical to that caused by systemic autoimmune disease. This article, apart from reporting a case, is also a succinct review of posterior scleritis due to tuberculosis, which highlights the challenges in diagnosis and management of such cases.


  Case Report Top


A 47-year-old female presented to our clinic with complaints of diminution of vision in the left eye with ocular pain since 15 days. She consulted an ophthalmologist locally and was on topical steroids for last 10 days. There was a history of contact with a patient of pulmonary tuberculosis. On examination, her best corrected visual acuity (BCVA) was 6/6 in the right eye and 6/18 in the left eye. Slit-lamp examination of the left eye showed a quiet anterior chamber, cells in anterior vitreous. Pupils were normal and reactive in both the eyes and colour vision with Ishihara chart was 21/21 in both eyes. Slit-lamp and fundus examination of the right eye was unremarkable. Fundus examination of the left eye showed an oedematous optic disc with surrounding subretinal fluid and scattered multiple, discrete areas of choroiditis in mid- and far-periphery [Figure 1]a. Ultrasound B-scan of the left eye demonstrated sclerochoroidal thickening with widening of sub-Tenon space with scant fluid and elevation of optic papilla [Figure 1]b. Fundus fluorescein angiography (FFA) of the left eye showed early disc staining and peripapillary pin-head leaks in the early phase of angiogram which gradually showed pooling around the disc in late phases [Figure 2]a and [Figure 2]b. Multiple patches of choroiditis could be appreciated as early hypofluorescence and late hyperfluorescence in FFA. Indocyanine angiography (ICG) delineated much more areas of choroidal inflammation which were not visible clinically or in FFA [Figure 2]c and [Figure 2]d.
Figure 1: (a) Colour fundus montage photograph of the left eye showing an oedematous optic disc with peripapillary subretinal fluid and scattered multiple, discrete areas of choroiditis. (b) Ultrasound B-scan of the left eye showing sclerochoroidal thickening, widening of sub-Tenon space with scant fluid and elevation of optic papilla. (c) Colour fundus montage photograph of the left eye showing complete resolution at 4-month follow-up. (d) Ultrasound B-scan of the left eye showing resolution of the inflammation

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Figure 2: (a and b) FFA of the left eye showing early disc staining and peripapillary pin-head leaks in the early phase of angiogram followed by pooling of the dye around the disc in late phases. Multiple patches of choroiditis could be appreciated as early hypofluorescence and late hyperfluorescence in the angiogram. (c and d) Early and late phases of ICG delineated much more areas of choroiditis

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She was extensively investigated for the cause of her scleral inflammation. Her erythrocyte sedimentation rate was elevated, and serum angiotensin converting enzyme and serum lysozyme were within normal limits. Anti-nuclear antibody, rheumatoid factor, anti-cytoplasmic antibodies, serologies for syphilis were negative. Her Mantoux test was strongly positive (28 mm) and high resolution computerised tomography (HRCT chest) revealed enlarged mediastinal lymph nodes with apical scarring. A consultation with chest physician was sought, who started her on anti-tubercular treatment (ATT), that is, rifampicin 10 mg/kg, isoniazid 5 mg/kg, pyrazinamide 25 mg/kg and ethambutol 20 mg/kg for 9 months. She was administered intravenous methylprednisolone 1 g for 3 days and started on oral corticosteroid 60 mg/day in tapering schedule.

She was seen after a month, when her BCVA in left eye improved to 6/9. Slit-lamp examination revealed a quiet anterior chamber and anterior vitreous. Fundus examination of the left eye showed resolving optic disc edema with surrounding subretinal fluid and choroiditis lesions. After 4 months, her BCVA improved to 6/6. Fundus examination of the left eye revealed complete resolution of optic disc edema, resolution of surrounding subretinal fluid and healing of the choroidal lesions with minimal retinal pigment epithelium hyperperturbations [Figure 1]c. A repeat USG B-scan of the left eye demonstrated marked reduction in sclerochoroidal thickening and resolution of the optic nerve head [Figure 1]d. She was advised to stop oral corticosteroid and continue ATT. She is under follow-up with us for last 6 months and till now she did not develop any recurrence.


  Discussion Top


Posterior scleritis a is relatively rare cause of scleral inflammation and even rarer is tubercular posterior scleritis.[1],[6] Scleral tuberculosis may result from either direct infection by Mycobacterium tuberculosis or an immune-mediated mycobacterial antigen-mediated inflammation.[6] Definitive diagnosis of tuberculous scleritis ideally should be based on the evidence of M. tuberculosis in scleral biopsy, which is not feasible in majority of the cases because of the difficulty in obtaining proper tissue specimen and paucibacillary nature of the infection. Scleral tuberculosis remains a presumptive clinical diagnosis largely based on a presumptive evidence of systemic infection such as positive Mantoux test, radiographs showing pulmonary involvement, positive biopsy of the lymph node and/or scleritis not responding adequately to conventional immunomodulation alone.[7]

We conducted a detailed review of the literature on PUBMED using terms such as posterior scleritis, tuberculosis, tuberculoma. Additional studies were identified from the bibliographies of the retrieved articles. Previous to this report, only four cases of tuberculous posterior scleritis were reported in literature [Table 1]. One case report was not included as it was in French.[8] There are paucity of literature on tuberculous posterior scleritis.[7],[9] However, these data should be interpreted with caution as in many of these studies are from non-endemic populations for tuberculosis and often diagnostic evaluation for tuberculosis was not extensive.[7] In a series of 83 scleritis patients from Japan,[7] 76% patients underwent Mantoux test evaluation and in 46% patients with positive Mantoux test, tuberculosis was identified as the cause of scleral inflammation. In all of these patients, scleritis responded to only ATT without any immunomodulation.[7] In a case series on scleritis in patients <16 years of age, we reported a 13-year-old child who had both necrotizing scleritis and posterior scleritis.[9] In another case series of 13 children with posterior scleritis by Cheung and Chee,[10] all patients had negative Mantoux tests and normal radiographs.
Table 1: Review of literature of cases with tuberculous posterior scleritis

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Posterior scleritis is known to show a female preponderance and similar observation noted in all reported cases of tuberculous posterior scleritis including ours. A presumptive association of tuberculosis was considered in our patient as she had strongly positive Mantoux and HRCT chest was suggestive of tuberculosis. She was thoroughly examined by a chest physician and started on ATT. Unlike four patients with tuberculous posterior scleritis reported in literature, our patient gave history of contact with patient of pulmonary tuberculosis.[5],[11],[12],[13]

Posterior scleritis has plethora of presentations and various fundus signs has been described in patients with tuberculous posterior scleritis. Our patient presented with oedematous disc with surrounding subretinal fluid and ultrasound B-scan demonstrated sclerochoroidal thickening with widening of sub-Tenon space. These findings were associated with multifocal choroiditis and ICG helped us to delineate more subclinical areas of choroidal inflammation. To the best of our knowledge, posterior scleritis with concurrent choroiditis has not been reported in literature. Pappuru and Dave[13] described a patient with tuberculous posterior scleritis who presented with concurrent subretinal abscess.

Miranda et al.[11] described a case of posterior scleritis in a healthy 43-year-old woman which presented as choroidal folds, optic disc oedema, and exudative retinal detachment. The patient presented with complaints of painful reduced visual acuity and periorbital oedema and proptosis of the eye. As observed in our patient, there was no conjunctival or ciliary hyperaemia and anterior chamber reaction in their patient. Gupta et al.[5] described a case of posterior scleritis in a patient with histopathologically proven systemic tuberculosis who had a history of recurrent anterior uveitis before presenting with posterior scleritis. Our patient with posterior scleritis had a positive Mantoux, pulmonary invovlment in HRCT chest and subsequently responded to a combination of systemic corticosteroids and ATT. Ideally, ATT alone resulting in resolution of scleritis may have strengthened the causal association with M. tuberculosis. Posterior scleritis with optic disc involvement is a sight-threatening disorder and warrants aggressive systemic therapy. However, tuberculous posterior scleritis has been reported in patient in absence of presumptive evidence of tuberculosis.[12] Velasco e Cruz et al.[12] described a large peripapillary posterior scleral tuberculoma in a 66-year-old diabetic female with rheumatoid arthritis who was on oral corticosteroid and oral immunosuppressive for last 8 years. Her Mantoux test was negative and chest radiograph was normal. The eye was enucleated in suspicion of choroidal melanoma and histopathogical examination of enucleated specimen revealed a granuloma with caseation limited to the sclera and acid-fast bacilli were found in sections with Ziehl-Nielsen staining. Owing to its high vascularity, choroid is the most common site for tubercular granuloma formation in eye. Though uncommon, large posterior tubercular granuloma can involve sclera as solitary mass mimicking a tumour especially following long-term immunosuppression.[12] The rich vascular plexus around the optic nerve was attributed to the peripapillary involvement of the scleral tuberculoma.[12]

Tuberculous scleritis, though extremely rare, can present with posterior scleral involvement. High index of suspicion and appropriate investigations can help one to clinch the diagnosis of tuberculosis in a case of posterior scleritis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Benson WE. Posterior scleritis. Surv Ophthalmol 1988;32:297-316.  Back to cited text no. 1
    
2.
Fahim K, Houghton O, Dastjerdi M, Mian SI. Posterior scleritis secondary to Pseudomonas aeruginosa keratitis. Cornea 2005;24:879-81.  Back to cited text no. 2
    
3.
Krist D, Wenkel H. Posterior scleritis associated with Borrelia burgdorferi (Lyme disease) infection. Ophthalmology 2002;109:143-5.  Back to cited text no. 3
    
4.
Tranos PG, Ong T, Nolan W, Manzouri B, Forbes J. Posterior scleritis presenting with annular choroidal detachment as a complication of herpes zoster ophthalmicus. Retina Phila Pa 2003;23:716-7.  Back to cited text no. 4
    
5.
Gupta A, Gupta V, Pandav SS, Gupta A. Posterior scleritis associated with systemic tuberculosis. Indian J Ophthalmol 2003;51:347-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Bloomfield SE, Mondino B, Gray GF. Scleral tuberculosis. Arch Ophthalmol Chic Ill 1960 1976;94:954-6.  Back to cited text no. 6
    
7.
Keino H, Watanabe T, Taki W, Nakashima C, Okada AA. Clinical features and visual outcomes of Japanese patients with scleritis. Br J Ophthalmol 2010;94:1459-63.  Back to cited text no. 7
    
8.
Chan H, Ailem Y, San S, Rougier MB, Montferme S, Dutheil C, et al. Tuberculoma associated with bilateral posterior scleritis secondary to lymph node tuberculosis: A case report. J Fr Ophtalmol 2016;39:e151-5.  Back to cited text no. 8
    
9.
Majumder PD, Ali S, George A, Ganesh S, Biswas J. Clinical profile of scleritis in children. Ocul Immunol Inflamm 2018;1-5.  Back to cited text no. 9
    
10.
Cheung CMG, Chee S-P. Posterior scleritis in children: Clinical features and treatment. Ophthalmology 2012;119:59-65.  Back to cited text no. 10
    
11.
Miranda AF, Cardoso J, Marques N, Barros S, Telles P, Campos N. Isolated posterior scleritis associated with tuberculosis. Arq Bras Oftalmol 2016;79:111-2.  Back to cited text no. 11
    
12.
Velasco e Cruz AA, Chahud F, Feldman R, Akaishi PMS. Posterior scleral tuberculoma: Case report. Arq Bras Oftalmol 2011;74:53-4.  Back to cited text no. 12
    
13.
Pappuru RR, Dave VP. An unusual case of ocular tuberculosis presenting as subretinal abscess with posterior scleritis. Int Ophthalmol 2017;37:285-9.  Back to cited text no. 13
    


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