Author: Chekitaan Singh (India)
Co-authors: Reena Gupta, Ishwar Singh, Prajjwal Kumar
Purpose
Through this case report we highlight the various examination, investigative techniques and therapeutic strategies which allowed us to successfully manage a challenging case of combined anterior and posterior scleritis of presumed tubercular origin which had already caused severe vision loss in the patients other eye.
Setting/Venue
Ishwar Eye Center, a tertiary care eye hospital in Northern India.
Methods
History of presenting complaints, previous history was taken. Best corrected Snellen visual acuity(BCVA) for both the eyes (OD-right eye, OS-left eye) was recorded. Torch light examination to detect scleritis , slit lamp biomicroscopy(SLE) & photography, fundus exam with indirect ophthalmoscopy(IDO), Ultrasound -B-scan, fundus photography, fluorescein angiography(FFA), funds auto-fluorescence(FAF) and optical coherence tomography(OCT) were performed and analysed. Tailored laboratory investigations were ordered and reviewed. topical and systemic steroids were started along with anti-tubercular therapy. immunosuppressives were later added to the regimen to control recurrences of inflammation
Results
28 year old asian female patient presented with severe pain and loss of vision in both her eyes, recent onset insight eye.BCVA : OD:6/60, OS:CFCF. SLE : OD: vascular scleral nodule temporal quadrant, AC cells 1+, flare 1+, Via. cells 2+ IDO: OD: hyperaemic disc, temporal retina-choroidal nodular elevation, OS: pale disc noted, full thickness macular hole and healed peripheral Choroiditis patches noted Ultrasound -B scan - OD: Peripappilary choroidal thickening with "T" sign noted FFA : OD: pin point focal hyper fluorescence noted in the temporal quadrant with hot disc OCT : OD : wavy RPE elevations noted with sub-retinal fluid pockets Lab investigations showed increased ESR, Mantoux test was positive, chest x-ray -normal the patient was started on topical and systemic steroids under cover of anti-tubercular therapy. both anterior and posterior scleritis showed good resolution upto 6 months with good recovery of BCVA in OD to 6/9. subsequently there were multiple recurrences which were controlled with addition of immunosuppression(Azathioprine 150mg/day) which resulted in steroid sparing and ensured disease remission. the patient is now 14 months follow-up is on tapering dose steroids and immunosuppression and is maintaining BCVA 6/9 IN OD
Conlusions
Combined anterior and posterior scleritis requires a very good clinical evaluation, investigations and a more aggressive therapeutic regimen to control a decidedly more inflammed eye and if not managed appropriately can land up in severe vision loss and corresponding visual morbidity for the patient. Geographic location of the patient, healed Choroiditis patches in the other eye, poor social economic status, a positive Mantoux test and increased ESR made us decide to add anti-tubercular therapy to our treatment regimen. Immunosuppressive therapy helped us bring the recurrences under check and also allowed the steroids to be tapered below 10mg/day, which is a safer dose for one term use
Financial Disclosure
NO FINANCIAL RELATIONS
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