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   Table of Contents      
Year : 2003  |  Volume : 51  |  Issue : 4  |  Page : 351-353

posterior scleritis mimicking macular serpiginous choroiditis

Department of Ophthalmology, Govt. Medical College Hospital, Chandigarh, India

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Department of Ophthalmology, Govt. Medical College Hospital, Chandigarh
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PMID: 14750626

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An unusual case of posterior scleritis mimicking macular serpiginous choroiditis is reported

Keywords: Posterior scleritis, serpiginous choroiditis

How to cite this article:
Sonika, Narang S, Kochhar S, Srivastava M, Gupta R, Sood S. posterior scleritis mimicking macular serpiginous choroiditis. Indian J Ophthalmol 2003;51:351-3

How to cite this URL:
Sonika, Narang S, Kochhar S, Srivastava M, Gupta R, Sood S. posterior scleritis mimicking macular serpiginous choroiditis. Indian J Ophthalmol [serial online] 2003 [cited 2020 Nov 26];51:351-3. Available from: https://www.ijo.in/text.asp?2003/51/4/351/14647

The diagnosis of posterior scleritis still remains a clinical challenge due to its varied ocular presentation and systemic associations. The presentation of posterior scleritis as disc oedema, serous retinal detachment, vasculitis, choroidal or retinal infarction, vessel occlusions, choroiditis, ocular lymphoma, birdshot chorioretinopathy and fundus mass lesion is known.[1],[2],[3],[4],[5],[6] We report an unusual case of posterior scleritis mimicking macular serpiginous choroiditis.

  Case report Top

A 40-year-old male presented with painful diminution of vision in the left eye of 15 days' duration. The systemic history and examination were unremarkable. The visual acuity was 6/6 in the right eye and counting fingers at 1m in the left eye. The right eye was essentially normal. Ocular movements in the left eye were painful but not restricted. Intense conjunctival chemosis obscured scleral examination for vascularity or oedema. A relative afferent pupillary defect was present and slitlamp biomicroscopy of anterior segment and vitreous did not show any inflammatory cellular reaction. Fundus examination with +90 D lens revealed disc oedema with hyperemia, choroidal folds and a 2 disc diameter creamish choroidal lesion with serpiginous fuzzy margins. There was associated retinal oedema in the posterior pole involving the fovea [Figure - 1]. Fundus Fluorescein Angiography (FFA) showed hypofluorescene in the early phase [Figure - 2]a; the late dye transit phase showed advancing hyperfluorescence of edges [Figure - 2] b,c and disc staining [Figure - 2]d. In view of conjunctival chemosis, disc oedema and choroidal folds, unusual for macular serpiginous choroiditis, ultrasonography (USG) B-Scan was done. USG B-Scan demonstrated increased thickness (maximum of 0.34 cm) of the outer coats of the eye in the posterior pole with an adjacent echolucent area. A similar echolucent area also surrounded the optic nerve, with the typical T sign [Figure - 3]a. Colour Doppler showed increased vascularity in the choroidal region temporal to the optic disc [Figure - 4]a. The findings were consistent with posterior scleritis with macular serpiginous choroiditis. Systemic investigations including ESR, chest X-ray, VDRL, HIV titre, ANA, ANCA, rheumatoid factor, serum uric acid and C-Reactive protein were inconclusive. Mantoux test was negative.

The patient was started on oral prednisolone 100 mg once a day. Within 24 hours of starting the treatment, the conjunctival chemosis reduced, disc oedema began to resolve and the choroiditis patch became well-defined. After one week, a USG B-Scan showed decrease in thickness (maximum of 0.19 cm) of the outer coats of the eye [Figure - 3]b. Colour Doppler showed decrease in vascularity in the choroidal region. [Figure - 4]b. The vision in the left eye improved to 6/12, conjunctival chemosis reduced, disc oedema resolved and the posterior pole lesion resolved with pigmentation.

  Discussion Top

The diagnosis of posterior scleritis still remains a clinical challenge. The final outcome depends on the promptness of treatment. Early diagnosis needs a high index of suspicion and awareness of the varied presentations of posterior scleritis. Posterior scleritis is associated with numerous systemic and ocular diseases such as connective tissue disorders, Wegener's granulomatosis, tuberculosis, syphilis, gout, choroidal infarction, vascular occlusions, vasculitis, infective choroiditis, lymphoma and birdshot choroidopathy.[1],[2],[3],[4],[5]To the best of our knowledge the association of macular serpiginous choroiditis and posterior scleritis has not yet been reported.

In the present case, the posterior pole findings of serpiginous choroiditis could not explain intense conjunctival chemosis and painful ocular movements. The presence of these symptoms in association with disc oedema and choroidal folds hinted at associated posterior scleritis. The ultrasonography and colour doppler confirmed the diagnosis. Posterior scleritis may present as conjunctival chemosis in 50% cases and ocular pain in more than 90% cases. Optic disc oedema, serous retinal detachment and choroidal folds are important diagnostic signs of posterior scleritis.[1] Choroiditis, if associated with posterior scleritis is severe and usually infective in origin. The contiguous inflammation of sclera, choroid, retina and vitreous is documented. Wilhelmus noted vasculitis in choriocapillaries, perivascular cuffing of central retinal artery and posterior ciliary vessels associated with scleritis.[7] In the present case , contiguous inflammation was evident from the ultrasonographic findings of increased thickening of the outer coats of eye, Colour Doppler showed increased posterior pole vascularity, probably contributing to disc oedema and macular serpiginous choroiditis. However, the vitreous cavity was clinically free of inflammation. Contiguous choroidal inflammation has not been documented earlier in macular serpiginous choroiditis, an idiopathic condition. The association of posterior scleritis with macular serpiginous choroiditis explains the presence of contiguous inflammation.

The response to systemic corticosteroids was remarkable in our patient. This case highlights the fact that severe forms of posterior scleritis could also mimic macular serpiginous choroiditis. The response to systemic corticosteroids is good in the absence of any other systemic disease.

  References Top

Calthorpe CM, Watson PG, McCartney ACE. Posterior scleritis: A clinical and histological survey. Eye 1988;2:267-77.   Back to cited text no. 1
Frost NA, Sparrow JM, Rosenthal AR. Posterior scleritis with retinal vasculitis and choroidal and retinal infarction. Br J Ophthalmol 1994;78:410-12.   Back to cited text no. 2
Benson WE. Posterior scleritis. Surv Ophthalmol 1988;32:297-16.   Back to cited text no. 3
Hoang-Xuan T, Bodaghi B, Toublanc M, Delmer A, Schwartz L, D Hermies F. Scleritis and mucosal- associated lymphoid tissue lymphoma: A new masquerade syndrome. Ophthalmology 1996;103:631-35.  Back to cited text no. 4
Cunningham ET Jr, Sabrosa NA, Pavesio CE. Posterior scleritis mimicking birdshot retinochoroidopathy. Eye 2001;15:231-33.   Back to cited text no. 5
Gedde SJ, Augsburger JJ. Posterior scleritis as a fundus mass. Ophthalmic Surg 1994; 25:119-21.   Back to cited text no. 6
Wilhelmus KR, Grierson I, Watson PG. Histopathology and clinical associations of scleritis and glaucoma. Am J Ophthalmol 1981;91:697-705.  Back to cited text no. 7


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

This article has been cited by
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Lim, W.-K., Buggage, R.R., Nussenblatt, R.B.
Survey of Ophthalmology. 2005; 50(3): 231-244


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