Scleritis, keratitis, and orbital cellulitis: isolated ocular manifestation of systemic lupus erythematosus

Systemic autoimmune diseases are associated with ocular inflammatory conditions such as episcleritis, scleritis, keratitis, and uveitis. However, ocular manifestations have been reported to correlate with the extent of systemic disease. We present a patient with scleritis, keratitis, and orbital cellulitis, as the isolated manifestation of systemic lupus erythematosus (SLE). No microbial etiology was identified and antibiotics did not produce clinical improvement. The patient improved significantly with steroids and disease-modifying antirheumatic drugs. Although ocular inflammation has been previously remarked in SLE of systemic severity, in this case there were no other organs with SLE involvement. We briefly discuss the ocular manifestations of SLE, which can involve all segments of the eye, including cornea, sclera, retina, uvea, optic nerve, and orbit.

Atypical posterior scleritis mimicking choroidal melanoma

We report a case of atypical posterior scleritis mimicking amelanotic choroidal melanoma. A 30-year-old healthy Filipino man, with a history of painless subacute loss of vision in his left eye over 5 months, was referred to our institute for further workup and management. On examination, visual acuity of the left eye was 20/200. Anterior segment examination yielded unremarkable results, with injected conjunctiva and quiet episcleral blood vessels, while fundus examination revealed non-pigmented nasal choroidal mass, with significant subretinal fluid resembling amelanotic choroidal melanoma. Right eye examination yielded unremarkable results. The patient was diagnosed with atypical posterior scleritis, and treated with oral steroids for 2 weeks, with no improvement. A periocular steroid was then injected to the left eye, causing dramatic reduction in choroidal mass size, and complete resolution of subretinal fluid. The visual acuity improved to 20/28.5 one month after the injection. Timely treatment was crucial for minimizing vision-threatening complications.

[Scleritis and systemic diseases: What should know the internist?]

Scleritis is an inflammatory disease of the sclera; outer tunic of the eye on which the oculomotor muscles are inserted. It can be associated with a systemic disease up to one time out of 3. These associated diseases are mainly rheumatoid arthritis, vasculitis, including granulomatosis with polyangiitis in the first line and spondyloarthropathies. Before mentioning such an etiology, it is necessary to eliminate an infectious cause, mainly herpetic, which is regularly underestimated. The classification of scleritis is clinical. We distinguish between anterior scleritis and posterior scleritis. Anterior scleritis is diffuse or nodular, usually of good prognosis. Anterior necrotizing scleritis with inflammation is often associated with an autoimmune disease, necrotizing scleritis without inflammation usually reflects advanced rheumatoid arthritis. The treatment of these conditions requires close collaboration between internists and ophthalmologists to decide on the use of corticosteroid therapy with or without immunosuppressors or biotherapies.

Ocular Manifestations in Patients with Microscopic Polyangiitis

PURPOSE

To describe ocular manifestations in patients with microscopic polyangiitis.

METHODS

Two patients with microscopic polyangiitis complained of ocular symptoms and underwent ophthalmologic examinations.

RESULTS

An 83-year-old woman (Case 1) was diagnosed with microscopic polyangiitis, according to the general clinical findings and the presence of perinuclear pattern of antineutrophil cytoplasmic antibodies (P-ANCA). She had hypopyon iridocyclitis in the right eye and retinal cotton-wool spots in the left eye. The patient was treated with oral prednisolone and subconjunctival betamethasone. The hypopyon iridocyclitis and retinal cotton-wool spots responded. A 79-year-old man (Case 2) had bilateral scleritis. The diagnosis of microscopic polyangiitis was made based on general clinical findings and the presence of P-ANCA. Scleritis was reduced after corticosteroid treatment.

CONCLUSIONS

Ophthalmologists should be aware that hypopyon iridocyclitis, cotton-wool spot, and scleritis could occur in patients with microscopic polyangiitis.

[Scleritis and episcleritis]

Episcleritis is generally a benign disease with a self-limited course, while scleritis is a severe ocular condition due to a risk of impaired vision in one-fifth of patients and its association with systemic diseases in one third of them. Infectious scleritis, representing 8 % of the etiologies, is mainly of herpetic origin (varicella zoster and herpes simplex viruses). A systemic autoimmune disease is observed in roughly 30 % of scleritis patients: inflammatory rheumatisms (15 %), firstly rheumatoid polyarthritis, systemic vasculitides (8 %), mainly granulomatosis with polyangiitis (Wegener's) and polychondritis, and less often inflammatory bowel disease and systemic lupus erythematosus. Among the different types of scleritis, a clear distinction exists between necrotizing forms leading to decreased vision in 50 % of the cases and associated with systemic diseases in the vast majority, and non-necrotizing forms (either diffuse or nodular), with a better prognosis. However, recent publications show that necrotizing forms are much less frequent nowadays (around 5 % of the total), probably due to therapeutic innovations and progress made during the last 20 years. The medical management of scleritis requires collaboration between ophthalmologists and internists (or rheumatologists).

[Diagnosis and treatment of episcleritis and scleritis]

Episcleritis is a benign and self-limiting disease, often with a recurrent course, manifesting mainly in young adults. In less than a third of patients, an associated systemic disease can be found. In contrast, scleritis is observed mainly in patients between the 4th and 6th decade of life, may lead to severe ocular complications, and is often associated with a systemic rheumatological disease. Diffuse, nodular, and necrotizing forms of scleritis can be differentiated. Necrotizing and posterior scleritis have a higher risk of complications and worse visual outcome. In most cases, medical history and slit lamp examination allow differentiation of episcleritis and scleritis. Whereas episcleritis is treated mainly symptomatically with artificial tears, topical corticosteroids, and potentially with systemic nonsteroidal anti-inflammatory drugs, scleritis requires early and aggressive anti-inflammatory treatment in a stepwise approach.

IgG4-related disease presenting as posterior scleritis and vitritis, progressing to multifocal orbital involvement

IgG4-related disease (IgG4-RD) is a rare, chronic inflammatory condition that may involve nearly every organ system. Originally identified as a cause of autoimmune pancreatitis, its characteristic histological and clinical features have been found in a wide variety of inflammatory presentations, including the eye and orbit. Here we describe an example of a case of IgG4-RD initially presenting as scleritis and vitritis, with further progression to multifocal bilateral orbital involvement. Tissue biopsy of an orbital mass was highly characteristic of IgG4-RD histology and a rapid clinical response to corticosteroids was observed. This case highlights IgG4-RD as a rare cause of intraocular inflammation that may progress to involve the orbit.

Poststreptococcal syndrome presenting as posterior scleritis in a child

Posterior scleritis in children is very rare. In contrast to the adult form, pediatric posterior scleritis has not previously been associated with any systemic disorder. We describe a case of an 11-year-old girl who presented with left eye pain and redness and was found to have posterior scleritis on ultrasonography. Her laboratory work-up revealed a highly elevated antistreptolysin O titer; the rest of her serologic and radiologic evaluation was unremarkable. She was diagnosed with presumed poststreptococcal posterior scleritis and improved with a slow taper of oral steroids.

Subcorneal pustular dermatosis and episcleritis associated with poorly controlled ulcerative colitis

A man aged 56 years with a history of ulcerative colitis (UC) status postsubtotal colectomy was hospitalised with fevers, dry cough, eye redness and a new bloody, mucoid rectal discharge. 2 months prior to admission, the dermatologist had started him on dapsone for subcorneal pustular dermatosis but did not recognise that he had recently self-discontinued mesalamine enemas, inducing a flare of his UC. After a thorough inpatient evaluation, including flexible sigmoidoscopy, active UC involving the rectal stump was determined to be driving his dermatological and ophthalmological findings. By reinstituting mesalamine enemas, control of his UC was achieved and the extraintestinal manifestations of his inflammatory bowel disease (IBD) resolved. This case illustrates the importance of careful history taking and of early recognition of extraintestinal manifestations of IBD in order to appropriately target treatment and prevent unnecessary morbidity.

Gevokizumab in the Treatment of Autoimmune Non-necrotizing Anterior Scleritis: Results of a Phase I/II Clinical Trial

PURPOSE

To evaluate the safety and potential efficacy of gevokizumab, an anti-interleukin 1β (IL-1β) monoclonal antibody, in the treatment of active, noninfectious, non-necrotizing anterior scleritis.

DESIGN

Phase 1/2, open label, nonrandomized, prospective, single-arm pilot trial.

METHODS

Eight patients with active, noninfectious, non-necrotizing anterior scleritis with a scleral inflammatory grade of +1 to +3 in at least 1 eye were enrolled. In 1 patient both eyes were enrolled, for a total of 9 eyes (4 eyes with +1, 1 eye with +2, and 4 eyes with +3). Patients received 1 subcutaneous injection of 60 mg gevokizumab at baseline and then every 4 weeks for 12 weeks. Complete physical and ocular examinations were performed at each visit. The primary outcome was at least a 2-step reduction or reduction to grade 0 in scleral inflammation on a 0 to +4 scale according to a standardized photographic scleritis grading system by 16 weeks in the study eye compared to baseline. Secondary outcomes included changes in visual acuity, intraocular pressure, and trends in scleral grading. Participants who met the primary outcome were eligible to continue in the study for up to 52 weeks and received additional gevokizumab injections every 4 weeks until week 36, followed by 2 safety visits at weeks 40 and 52.

RESULTS

Seven eyes from 7 patients met the primary outcome within a median time of 2 weeks following the first gevokizumab injection. No definitive changes in visual acuity or intraocular pressure were identified. There were no serious adverse events related to the study drug. A total of 43 adverse effects were reported, with 93% described as mild, 95% as nonocular, and only 14% deemed possibly caused by the investigational treatment.

CONCLUSIONS

The results of this small study suggest that blockage of IL-1β using gevokizumab may be beneficial in treating active, noninfectious anterior scleritis and that gevokizumab is well tolerated. Larger randomized trials are warranted to assess the true efficacy of gevokizumab in the treatment of non-necrotizing anterior scleritis.

Interleukin-22 serum levels are elevated in active scleritis

PURPOSE

To evaluate serum cytokine profile from patients with active scleritis in a two-centre prospective case-control study.

METHODS

The serum of 20 active scleritis patients not treated with any local, periocular, or systemic immunomodulatory therapy (IMT) was analysed with multiplex assay to determine the levels of 11 cytokines interleukin (IL)-1β, IL-6, IL-2, IFN-γ, IL-10, IL-12p40, IL-13, IL-17A, IL-5, TNF-α, and TNF-β, and with ELISA to determine the levels of TGF-β1, IL-22, and IL-23. Twenty-five age-matched healthy volunteers were used as controls. In a subgroup of 13 patients with active disease, a second serum sample was obtained when the disease was inactive and levels of IL-22 were determined. Serum IL-22 levels from patients with active scleritis were correlated with type of scleritis (non-necrotizing and necrotizing), degree of inflammation (0-4+ :≤2+ and >2+), and associated systemic disease.

RESULTS

Serum levels of IL-22 were elevated in active scleritis patients compared to controls (6.41 ± 1.52 pg/ml versus 1.93 ± 0.39 pg/ml, p = 0.012) and significantly decreased after scleritis remission with the use of IMT (p = 0.005). There was no statistical association with scleritis type, degree of inflammation, or associated systemic disease. The serum levels of other cytokines were not significantly different from controls.

CONCLUSION

In our study cohort, IL-22 serum levels were significantly elevated in active scleritis patients compared to controls and decreased significantly after remission. Our results suggest that IL-22, a T helper (Th) 17- and Th22- derived cytokine, may play a critical role in the physiopathology of scleritis.

Nodular Posterior Scleritis Mimicking Choroidal Tumor in a Patient With Systemic Lupus Erythematous: A Case Report and Literature Review

PURPOSE

Posterior scleritis is a potentially blinding ocular disorder that is often difficult to diagnose because of the low incidence and varied clinical presentation. Nodular posterior scleritis can mimic a choroidal mass and pose diagnostic difficulties to clinicians. This case report and literature review aimed to evaluate the clinical presentation of nodular posterior scleritis that mimics choroidal tumor, along with the etiologies, treatment modalities, and outcomes.

DESIGN

Case report and literature review.

METHODS

We describe a case of nodular posterior scleritis that presented as a choroidal mass in a patient with systemic lupus erythematous. Previous reports on nodular posterior scleritis presenting as choroidal mass were reviewed.

RESULTS

Including this case, there were 14 cases of nodular posterior scleritis presenting as a choroidal mass in the past 20 years. The mean age was 50 years, with women being predominant (79%). All cases had unilateral eye involvement. Most patients presented with a drop in vision (ranging from counting fingers to visual acuity of 20/30). The cause was mostly idiopathic in 79% of reported cases. Most patients (71%) were treated with a course of systemic steroids. Two patients required systemic steroids together with immunosuppressive agents. Most patients responded to treatment with visual recovery and resolution of the choroidal mass.

CONCLUSIONS

Nodular posterior scleritis is a rare disease that can easily be confused with choroidal tumor. Associated ocular pain is a useful feature for differentiating nodular posterior scleritis from other forms of choroidal masses. Early diagnosis and prompt treatment usually can deliver a good outcome.

[Posterior scleritis]

Posterior scleritis, a severe and painful inflammation of the sclera, is an often misdiagnosed pathology due to its clinical polymorphism. An accurate diagnosis is however needed in order to propose an appropriate treatment of the ophthalmologic symptoms and to exclude an associated systemic inflammatory or auto-immune pathology.

[Diagnosis and treatment approach for necrotizing scleritis (NS): A clinical case]

Necrotizing scleritis is an immune-mediated ocular inflammatory process, characterized by an area of avascular necrosis and a profound inflammation of the sclera and episclera. Necrotizing scleritis and its association with peripheral ulcerative keratitis--necrotizing sclerokeratitis (NS)--represents a serious threat for vision and eye integrity, evolves very fast if untreated, and its finding suggests the presence of a potentially lethal systemic vasculitic process. The following case is an example of the diagnostic approach and therapeutic scale in a 63-year-old women with necrotizing sclerokeratitis.

Optical coherence tomography in the diagnosis of scleritis and episcleritis

PURPOSE

To describe the optical coherence tomography (OCT) findings in eyes with active anterior scleritis and compare the findings to those with episcleritis and normal controls.

DESIGN

Prospective evaluation of a diagnostic test.

METHODS

We included a total of 30 eyes of 30 patients with unilateral anterior scleral or episcleral inflammation. The contralateral 30 eyes with no active ocular disease served as controls. OCT was performed over the anterior sclera in the inflamed area on all cases. The OCT images were analyzed to determine the thickness of the sclera and the presence or absence of scleral hyporeflective areas representing intrascleral edema.

RESULTS

There were 17 male and 13 female patients. The mean age was 43 years with an age range of 21-77 years. Eighteen patients had anterior scleritis and 12 patients had episcleritis. The mean transconjunctival scleral thickness was 747 μm (SD ± 68.97) with a range of 616-877 μm in normal eyes, 882 μm (SD ± 87.35) with a range of 773-1089 μm in patients with scleritis, and 825 μm (SD ± 85.57) with a range of 718-949 μm in patients with episcleritis.

CONCLUSIONS

Patients with active anterior scleritis showed increased thickness of the sclera and presence of intrascleral hyporeflective areas of edema by OCT compared to patients with episcleritis and normal eyes. OCT adds both qualitative and quantitative information to diagnosis and monitoring of patients with scleritis.

[Study on the clinical manifestation of 90 cases with scleritis and episcleritis]

OBJECTIVE

To evaluate the demographic characteristics, clinical features, ocular complications, and disease associations of patients who were diagnosed as scleritis and episcleritis in clinic.

METHODS

A retrospective case series study.Ninety patients were diagnosed clinically as scleritis and episcleritis in Beijing Tongren Hospital from Jan 2010 to Jan 2013. Analyzed the general states of health, case history, the clinical manifestation, clinical features, ocular complications (decrease in vision, anterior uveitis, keratitis, ocular hypertension, cataract, and diseases of retina), and disease associations, to summarize the clinical characteristics of scleritis and episcleritis.

RESULTS

Ninety patients were recorded, from 4 to 83 years old, and the average was (48 ± 15) years old. 30 cases (33.3%) were male, and 60 (66.7%) were female. There were no significant difference between male and female (χ² = 10.000, P < 0.01).In the 90 cases, 36 (40.0%) were episleritis and 54 cases (60.0%) were scleritis. Children group (0-16 years old) had 2 cases (2.2%), which all were episleritis.Young adult group (17-44 years old) had 39 cases (43.4%), including 13 were episleritis and 26 cases were scleritis. Middle adult group (45-59 years old) had 30 cases, including 9 cases episleritis and 21 cases scleritis. There were 19 cases (21.2%) in aged group ( ≥ 60 years), including 12 cases episleritis and 7 scleritis.Young adult group, Middle adult group and Aged group were significantly more than Children and aged group (χ² = 33.390, 24.500 and 13.762, P < 0.01).Young group was significantly more than Aged group Children group (χ² = 6.889, P < 0.01). Ocular complications were more frequent overall in patients with scleritis versus in those with episcleritis (χ² = 30.044, P < 0.01) , including decrease in vision, keratitis, and ocular hypertension (χ² = 130.200, 67.200, 54.444, P < 0.01) .Nineteen cases (21.1%) had different types of arthritis, and 10 cases (11.1%) had infection diseases in local. There were difference between episcleritis and scleritis (χ² = 145.644, P < 0.01) .

CONCLUSIONS

Scleritis occurs in all ages, but mainly in adults.It is uncommon, and potentially life-threatening diseases. It is needed pay attention to diagnosis and treatment of the patients with systemic disease and ocular complications by Ophthalmologist.

Red Alert: diagnosis and management of the acute red eye

The acute red eye represents a broad spectrum of disease encompassing benign self-limiting conditions to potentially vision-threatening ophthalmic or system disease. This article will review clinical principles essential for the diagnosis and treatment of red eye relevant to all Armed Forces primary care and emergency medicine practitioners.

Update in the management of extraintestinal manifestations of inflammatory bowel disease

Inflammatory bowel disease, comprised of Crohn's disease and ulcerative colitis, are chronic inflammatory disorders of the gastrointestinal tract. Up to 40 % of patients with inflammatory bowel disease can develop inflammation in other organ systems of the body. These extraintestinal manifestations (EIM) can affect the musculoskeletal, ocular, mucocutaneous, and hepatobiliary systems. Symptoms related to EIM can result in impaired quality of life, and complications of EIM can lead to disfigurement, functional deficits, and even life-threatening organ dysfunction. Some EIM parallel the activity of IBD, and respond to treatment of the underlying disease. Others, however, follow an independent course and require targeted treatment.

Posterior scleritis presenting with angle closure glaucoma

PURPOSE

To report a case of posterior scleritis associated with angle closure glaucoma and transient myopia.

METHODS

A previously healthy 29-year-old male was referred for YAG laser iridotomy to treat angle closure glaucoma. He was suffering from severe pain and vision loss in his right eye. Findings on examination were hyperemia, proptosis, and myopia measuring approximately 6 diopters. Diagnosis of posterior scleritis was made due to presence of choroidal thickening, sub-Tenon effusion and the classical "T" sign observed on orbital ultrasonography.

RESULTS

Treatment was initiated using oral prednisolone. After 8 days, the patient's symptoms regressed and visual acuity returned to 20/20.

CONCLUSIONS

Posterior scleritis is an often misdiagnosed eye disease. Pain is the main symptom and may be accompanied by decrease in visual acuity. Early diagnosis and treatment is important to avoid permanent visual loss.