Scleritis Case presentation

Dr. Saumil Sheth Resident, Sion Hospital.

Case presentation
Anand Jadhav, 46 year old male, residing at Mumbai presented with chief complaints of redness, pain and watering in the right eye 9 months back followed by a few days later in the left eye. He was diagnosed as having scleritis at a peripheral clinic and was started on topical steroids four times daily. His symptoms waxed and waned over the months with an added complaint of decreased vision, gradual onset since 6 months. He was also diagnosed to have an anterior uveitic episode 1 month back in the form of AC flare, cells, and iritis, for which he was treated on stepped up steroids with cycloplegics.

 He has had a past history of pulmonary TB 20 years back for which he received 6 months AKT. He has no other systemic illness and no complaints of joint pains with rash of any kind. He has also no family history of the same. Presently he is continued on topical steroids four times daily with homatropine eyedrops HS.

 Slit lamp findings on dilatation include evidence of both eyes scleral thinning temporally with uveal show, minimal congestion and scleral edema, with three avascular patches on left and one on right. There is presence of central PSC cataract both eyes with Grade I nuclear sclerosis. Rest of anterior segment is normal IOP by indentation tonometry is 11.2 mm Hg. Visual acuity OD is 6/12 and OS 6/6p corrected. Direct, indirect ophthalmoscopy and slit lamp biomicroscopy revealed no abnormality The patient had not been previously investigated

Classification of episcleritis
Nodular Diffuse - sectoral 70% - entire 30%

Classification of scleritis
Anterior 98% - Non necrotising diffuse 44% nodular 40% - Necrotising 14% inflammatory noninflammatory (scleromalacia perforans) Posterior 2%

Systemic associations of episcleritis

Erythema multiforme Erythema nodosum Penicillin allergy Chemical hypersensitivity Autoimmune disorders

Systemic associations of scleritis

Autoimmune disorders Rheumatoid arthritis WG PAN relapsing polychondritis SLE dermatomyositis Reiters syndrome Gout Chronic infections TB, syphilis Other systemic conditions Sarcoidosis, UC and Crohns disease Infective bacterial, viral, fungal, posttraumatic, postcataract, postpterygium

Pathogenesis of scleritis
Type III hypersensitivity reaction - if associated with systemic disease, inflammation is granulomatous with necrosis - if idiopathic, inflammation is nongranulomatous, with lymphoid follicles and granulation tissue with lesser necrosis

 Let us discuss the case step by step..

 Anand Jadhav, 46 year old male, residing at Mumbai presented with chief complaints of redness, pain and watering inBoth episcleritis 9 the right eye and scleritis are months back followed by a few days later in the Episcleritis: commoner in left eye. yrs. 20-50 complications females Scleritis differs of He was diagnosed v/s from as having scleritis at a Anterior scleritis Scleritis: episcleritis in redness, Episcleritis yrs. and 60-70 has episcleritis peripheralcompications was started on topical clinic pain,with watering of and acute onset Both Posterior times daily. are symptoms waxed scleritis: v/s His steroids four in 3 scleritis and episcleritis Classification of photophobia, tenderness resolutionyrs. >50 over the of 50% and wanedmonths, location, scleritis and oncomplications months with an added palpation, weeks to 2 bilateral in > posterior complaint ofof cases. Posterior decreased episcleritis pattern, scleritis selflimiting colour and vision, gradual onset scleritis is mainly since 6blanching of vessels, nad months. movabilityunilateral over sclera He was also diagnosed to have an anterior uveitic episode 1 month back in the form of AC flare, cells, and iritis, for which he was treated on stepped up steroids with cycloplegics.

 He has had a past history of pulmonary TB 20 years back for which he received 6 months AKT. Systemic associations of He has no other systemic illness and no scleritis in >50% complaints of joint pains with rash of any and allergic associations in kind. He has alsoepiscleritis 30% no family history of the same. Presently he is continued on topical steroids four times daily with homatropine eyedrops HS.

 Slit lamp findings on dilatation include evidence of both eyes scleral thinning Spreading Hb, CBC, ESR anterior temporally with uveal show, minimal scleritis and posterior LFT, RFT congestion and scleritis have scleral through Staphyloma edema, with three RA factor, Uric acid and ANCA avascularANA, anti DNA, C3sclera one on right. patches on left and thinned out chorioretinal will Differential of central PSC cataract both complications till complement, not immune There is presence CRP, occurwith IOP more optic nuclear 40 complexes than diagnosis ofDisc eyes 60% ofGrade Iis mm Hgmacula with necrotising and sclerosis. Rest of Scleral edema Xray chest, spine and blue sclera is normal anterior segmentinvolvement scleritis have ocularwith hip best on sacroiliac joint IOP by and systemic tonometry is 11.2 mm Hg. indentation ACE levels, slitlamp, USG, complications, 40% is and OS cause corrected. FTA ABS, Scleritis Visual acuity OD is 6/12 known to CT and UBM, 6/6p have poor visual acuity HLA B27 corneal 37% Direct, indirectwithin 5 involvement in and slit lamp MRI and 30% die ophthalmoscopy cases in form of stromal biomicroscopy revealed no abnormality yrs. keratitis, sclerosing keratitis The patient had not been and glaucoma and keratolysis previously in 13 % cases investigated

 My diagnosis for the above was: both eyes necrotising anterior scleritis of the inflammatory type with scleral thinning with posterior subcapsular cataract

Cyclophosphamide Methotrexate Azathioprine My line of management would be: Cyclosporine Tacrolimus Plasmapheresis IV methyl prednisolone

Detailed investigation, both biochemical and radiological Combined endoxan and pulse To start patient on systemic oral steroids with slow Surgical management: taper with or without non-steroidal Scleral immunosupressants patch grafting
Lamellar kplasty Fascia lata or periosteum Topical stepped up transplant steroids with slow taper ? Conjunctival recession ? Angiography guided Regular follow up for IOP, fundus and vision coagulation

Regular workup to assess side effects of steroids

Thank you