[Giant nodular posterior scleritis compatible with ocular sarcoidosis simulating choroidal melanoma]

CASE REPORT

A 30-year-old man was referred to our ocular oncology service with a diagnosis of amelanotic choroidal melanoma of the left eye. The following tests were performed: ophthalmoscopy, fluorescein angiography, indocyanine green angiography, ultrasonography, magnetic resonance imaging and biopsy.

DISCUSSION

The diagnosis of giant nodular posterior scleritis, as suggested by ultrasonography, was confirmed by biopsy. A comprehensive medical evaluation was performed, but no etiology was found. The histology revealed a granuloma compatible with ocular sarcoidosis. A rapid response was obtained by systemic steroid administration (1 mg/kg). Sarcoidosis continues to be a challenge in diagnosis. It is important to distinguish nodular posterior scleritis from choroidal melanoma.

Peripheral T-cell lymphoma presenting as sclerouveitis

PURPOSE

To report an unusual case of ocular peripheral T-cell lymphoma presenting as sclerouveitis.

METHODS

A 53-year-old woman presented with painful, unilateral sclerouveitis and was initially treated with antivirals and corticosteroids for what was presumed to be isolated ocular HSV infection with vasculitis. When she failed to improve the conjunctiva was biopsied and characterized by immunohistochemical and molecular methods. The literature regarding conjunctival T-cell lymphomas as well as lymphomas mimicking scleritis is reviewed.

RESULTS

Biopsies of a scleral/conjunctival nodule from the right eye were obtained on 2 occasions, the second of which revealed the presence of intermediate to large size lymphocytes that were CD3, T-cell intracellular antigen 1 and Granzyme B positive but CD56 and Epstein Barr virus negative. Polymerase chain reaction showed clonal T-cell receptor gamma rearrangements in DNA samples isolated from biopsy tissue. Another biopsy was obtained from a mucosal lesion in the oropharynx, which was shown to contain an identical T-cell receptor gamma rearrangement. These results led to the diagnosis of peripheral T-cell lymphoma. Conjunctival T-cell lymphomas have been reported in two other patients both of which also had involvement of upper airway structures. Five other reports of lymphoma mimicking scleritis are discussed.

CONCLUSIONS

Peripheral T-cell lymphoma should be considered in the differential diagnosis of patients who present with sclerouveitis of unknown etiology unresponsive to conventional therapy. If a conjunctival T-cell lymphoma is identified a systemic evaluation for lymphoma with particular attention to the upper airway is justified.

Anti-cyclic citrullinated peptide, rheumatoid factor, and ocular symptoms typical of rheumatoid arthritis

PURPOSE

To correlate the presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies and rheumatoid factor (RF) with ocular symptoms typical of rheumatoid arthritis (RA).

METHODS

The records of 451 patients who had been examined by an ophthalmologist and tested for anti-CCP antibodies over a 3-year period at the Mayo Clinic were reviewed. Records of 255 patients with titers of anti-CCP and RF were analyzed for ocular surface and inflammatory disease associated with ocular RA.

RESULTS

Of the 33 anti-CCP+/RF+ patients, all were diagnosed with RA; ocular surface disease was present in 11 (33%) and inflammatory disease in 7 (21%). Of the 17 anti-CCP-/RF+ patients, 4 were diagnosed with an unspecified inflammatory arthritis and 1 with rheumatoid arthritis; a separate 5 (29%) had ocular surface disease. Out of 5 anti-CCP+/RF- patients, 3 were diagnosed with RA but none had ocular symptoms. Out of 200 anti-CCP-/RF- patients, 32 (16%) had ocular surface disease and 2 (1%) had ocular inflammation. Of the 74 patients diagnosed with any form of inflammatory arthritis, anti-CCP+/RF+ patients had more and worse inflammatory ocular RA disease compared to the other groups.

CONCLUSIONS

Patients who were both anti-CCP and RF positive tended to have more and worse ocular disease. In patients diagnosed with an inflammatory arthritis, the presence of anti-CCP antibodies and RF provides useful information to ophthalmologists for identifying patients most at risk for inflammatory ocular disease.

Scleritis associated with hepatitis C: a case report and review of literature

There has been an increase in the complications associated with hepatitis C. Scleritis is one of the complications of the condition that is not routinely suspected, and thus underdiagnosed or missed, leading to delay in initiation of treatment. This case report will bring that to the attention of ophthalmologists so necessary systemic therapy can be instituted in a timely fashion.

Localized episcleritis-like lesions on both eyes in a patient with para nasal sinusitis

BACKGROUND

Some lesions on the ocular surface bear the danger of false diagnosis and, therefore, incorrect therapy.

CASE

Our patient suffered from a therapy refractory episcleritis-like disease in both eyes. The conjunctiva and episclera in the temporal inferior quadrant were locally reddened but we could not make a clear diagnosis even after ultrasonic investigation.

OBSERVATIONS

The patient was introduced to an ear, nose, and throat specialist and, by means of magnetic resonance techniques, acute sinusitis maxillaries on the right side was diagnosed but the smear remained sterile.

CONCLUSION

The red eyes were, therefore, manifestation of the sinusitis. He was treated systemically with penicillin and non-steroidal spray and the ocular lesions disappeared as a result of this therapy.

The prevalence of ocular involvement in patients with inflammatory bowel disease

PURPOSE

The aim of this prospective randomized clinical study was to evaluate the prevalence of ocular involvement in patients with inflammatory bowel disease (IBD).

MATERIALS AND METHODS

We prospectively evaluated 116 patients who went to the gastroenterology clinic with endoscopically proven IBD between December 2001 and February 2005. All patients were examined for evidence of ocular manifestations of IBD. Twenty patients had Crohn's disease and 96 had ulcerative colitis. The examination consisted of slit-lamp examinations, tonometry, visual acuity, and indirect ophthalmoscopy.

RESULTS

The mean age of the 116 patients with IBD who were enrolled was 40.6 +/- 14.4 years (range 16 to 75). Twelve of 20 patients (60%) with Crohn's disease and 22 of 96 patients (22.92%) with ulcerative colitis had ocular involvement. The most common ocular findings were conjunctivitis (8.62%) and blepharitis (6.9%) followed by uveitis (5.17%), cataract (5.17%), and episcleritis (3.45%). Extraintestinal complications were seen in 12 (35.3%) of 34 patients with ocular involvement and in 16 (19.5%) of 82 patients without ocular involvement.

CONCLUSION

Because the ocular complaints of IBD patients are often nonspecific, it may be helpful to performed eye examinations as a routine component in the follow-up of these patients. It is well-known that early diagnosis and treatment of ocular involvement may prevent serious ocular complications that could be associated with significant visual morbidity. In addition, clinicians should be aware that some ocular diseases, such as uveitis and scleritis, might precede a diagnosis of ulcerative colitis or Crohn's disease.

Bilateral surgically induced scleritis following phacoemulsification

We present a case of bilateral angle-closure glaucoma secondary to bilateral posterior scleritis with ciliochoroidal detachment following sequential phacoemulsification cataract extraction. To our knowledge, this is the first report of this complication.

Ocular manifestations associated with chikungunya

PURPOSE

To report ocular manifestations associated with chikungunya.

DESIGN

Retrospective, nonrandomized, observational case series.

PARTICIPANTS

Nine chikungunya patients with ocular involvement.

METHODS

All patients with chikungunya infection presenting with ocular complaints from September 2006 to October 2006 were included in the study. The infection was confirmed by demonstration of chikungunya immunoglobulin M antibody in sera of all patients. All patients underwent an ophthalmic examination including fundus photography, fundus fluorescein angiography, confocal microscopy of keratic precipitates, and optical coherence tomography. Positive ocular changes were recorded and tabulated.

MAIN OUTCOME MEASURES

Characteristics, frequency, and locations of ocular lesions found in the participants.

RESULTS

There were 9 patients with ocular lesions; 1 had nodular episcleritis, 5 presented with acute iridocyclitis, and 3 had retinitis. Four to 12 weeks before the development of ocular manifestations, all of these patients had fever. Although there were no specific changes of iridocyclitis that were diagnostic of the fever, the retinal changes were consistent with viral retinitis. All patients recovered from the infection with relatively good vision.

CONCLUSION

It appears that iridocyclitis and retinitis are the most common ocular manifestations associated with chikungunya, with a typically benign clinical course. Less frequent ocular lesions include episcleritis. All the patients responded well to the treatment with preservation of good vision. To the best of our knowledge, similar ocular manifestations associated with chikungunya infection have not been reported. In the differential diagnosis of iridocyclitis and retinitis with features suggestive of a viral infection, the entity of chikungunya-associated ocular changes should be considered in the regions affected by the epidemic.

Diagnosis of limited ophthalmic wegener granulomatosis: distinctive pathologic features with ANCA test confirmation

PURPOSE

To describe the clinical and histopathologic finding of very limited ophthalmic Wegener granulomatosis (WG).

METHODS

Thirteen patients with scleritis, orbitopathy, episcleritis, and panuveitis were studied. They presented without evidence of lung or kidney disease, though eight had sinus involvement. We reviewed the biopsies for histopathologic findings consistent with WG, and tested for antineutrophil cytoplasmic antibodies antineutrophil cytoplasmic antibody (ANCA).

RESULTS

WG was suggested by granulomatous foci, collagen necrosis, neutrophils/nuclear dust, plasma cells and infiltrating eosinophils. Granular degeneration of the interstitial collagen; mummification of the collagen with disappearance of fibroblastic nuclei; and a polymorphous infiltrate exhibiting plasma cells, lymphocytes, neutrophils, and eosinophils within the epithelioid granulomas should suggest the diagnosis. ANCA test results supported the diagnosis of WG in all cases.

CONCLUSION

The described histologic characteristics are highly suggestive of WG. These findings along with clinical or laboratory findings, allow the diagnosis of very limited ophthalmic WG in the absence of systemic involvement.

Diagnostic and Therapeutic Challenge of Aspergillus flavus Scleritis

PURPOSE

To discuss the diagnostic and therapeutic challenges involved in the management of Aspergillus flavus scleritis and present a review of related literature.

METHODS

Case report and literature review.

RESULTS

A healthy 54-year-old woman presented with a 1-week history of severe pain and redness in her left eye. She was treated with prednisone for presumed idiopathic autoimmune scleritis after extensive evaluation revealed no apparent etiology. While on immunosuppressant therapy, the patient developed a scleral nodule that proved to be a scleral abscess with normal overlying scleral architecture. Culture of the abscess and extensive infectious disease evaluation did not offer an etiologic explanation. Biopsy of a subsequent scleral nodule revealed fungal hyphae on fixed tissue stains, and A. flavus was identified on fungal culture. The patient later acknowledged intravenous drug use in the 2 months preceding her presentation. Oral voriconazole and intravenous caspofungin along with repeated surgical drainage of emerging scleral abscesses eradicated the active disease after 3 months.

CONCLUSIONS

Despite its rare occurrence, Aspergillus sp. should be considered as a potential cause of an unusual progressive scleritis. Specific questioning regarding intravenous drug use may prove relevant. Scleral biopsy was instrumental in establishing the diagnosis. Aggressive multidrug medical therapy combined with repeated surgical debridement resulted in a positive clinical outcome.

[Subglottal stenosis as the first symptom of Wegener's granulomatosis]

A 51-year-old woman presented with a sore throat, hoarseness and difficulty in swallowing. On physical examination she was found to have stridor. Laryngoscopy revealed a subglottal stenosis. Infection was thought to be the cause but this was not confirmed by sputum or laryngeal cultures. Because of the clinical course and the presence of antineutrophil cytoplasmic proteinase-3 antibodies, Wegener's granulomatosis was diagnosed. Immunosuppressive therapy led to improvement. At 4-year follow-up the patient had scleritis but no ENT problems. Wegener's granulomatosis should always be considered in a patient with a subglottal stenosis; it can be the first symptom of this disease.

A case of posterior scleritis: differential diagnosis of ocular pain

Posterior scleritis is a rare cause of ocular pain, due to scleral inflammation, presenting with periocular pain, pain on movement and decreased vision. Although anterior scleritis may be associated with this condition, ocular signs may be absent. We report a case of posterior scleritis, presenting with right-sided ocular and periocular pain, exacerbated by ocular movements, irradiating to the ipsilateral temple and zygoma, not associated with visual disturbances at onset. Diagnosis was made with ultrasonography and confirmed by brain and orbital MRI. Differential diagnosis of facial pain, in particular, affecting the periorbital region, is discussed. In the presence of ocular pain, even in the absence of ocular signs, an ophthalmologic consultation should be performed.

Eye Manifestations in Patients with Perinuclear Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Case Series and Literature Review

PURPOSE

To report and summarize eye manifestations of patients with perinuclear pattern antineutrophil cytoplasmic antibody [pANCA, myeloperoxidase (MPO)-ANCA]-associated vasculitis.

METHODS

The medical records of four consecutive patients with pANCA (MPO-ANCA) vasculitis who showed eye manifestations were retrospectively reviewed. In addition, the medical literature databases, PubMed and Japana Centra Revuo Medicina for Japanese literature, were searched for pANCA vasculitis patients with eye manifestations.

RESULTS

Three of the four patients treated at the Okayama University Hospital showed unilateral or bilateral scleritis. In the literature review, eight of the 27 patients showed ocular surface manifestations such as scleritis and peripheral keratitis. Other frequent eye presentations were posterior segment manifestations such as central or branch retinal vein occlusion, optic neuropathy, and acute posterior multifocal placoid pigment epitheliopathy (APMPPE). Systemically, the most frequent manifestations were glomerulonephritis in the present patients as well as in the patients reported in the past studies.

CONCLUSIONS

Ocular surface manifestations and posterior segment manifestations were major eye presentations in patients with pANCA-associated vasculitis. ANCA testing including both pANCA and cytoplasmic pattern antineutrophil cytoplasmic antibody would help establish a systemic diagnosis in patients with eye manifestations such as scleritis, retinal vein occlusion, optic neuropathy, or APMPPE.

Therapy Insight: scleritis and its relationship to systemic autoimmune disease

The term scleritis describes a chronic inflammation that involves the outermost coat and skeleton of the eye. Disease can be isolated to the eye, but in up to half of affected individuals it occurs in the context of an immune-mediated systemic inflammatory condition, such as rheumatoid arthritis or Wegener's granulomatosis. Although uncommon, scleritis is often extremely painful, can lead to vision-threatening complications (and involvement of other ocular tissues), and is considered to confer an increased risk of mortality in patients with rheumatoid arthritis. Pathogenic mechanisms in scleritis are poorly understood, but enzymatic degradation of collagen fibrils by resident cells and infiltrating leukocytes seems to be a key feature. Several forms of inflammation can be distinguished histologically; interestingly, although the disease typically presents with engorgement of scleral vessels, vasculitis is not universally present at the microscopic level. Although some patients with scleritis respond well to treatment with NSAIDs, aggressive systemic therapy is often required to obtain a favorable outcome, particularly when systemic disease coexists. The mainstay of treatment is oral prednisone, but this agent is usually combined with a steroid-sparing immunosuppressive drug. New therapies presently under investigation for scleritis include local corticosteroid injections and various biologic agents.

Churg-Strauss syndrome associated with leukotriene receptor antagonists (LTRA)

Churg-Strauss syndrome (CSS) is a rare vasculitic disorder that generally occurs in patients with bronchial asthma. CSS is being increasingly recognized in asthmatic patients treated with leukotriene receptor antagonists. However, the nature of this relationship remains to be elucidated. The present report describes three asthmatic patients who developed clinical manifestations highly suggestive of CSS, although one patient lacked the presence of eosinophilia. The patient, however, exhibited biopsy-proven cutaneous necrotizing vasculitis, which improved after withdrawal of montelukast. The second patient presented with systemic constitutional signs including fever, malaise, arthralgias, clinical jaundice, peripheral blood eosinophilia, and biopsy-proven eosinophilic hepatitis. The third patient also had circulating eosinophilia, scleritis, and arthritis. All patients improved after discontinuation of the leukotriene receptor antagonist (montelukast).

Inverse hypopyon as the presenting feature of infectious scleritis in a case of tropical pyomyositis

CASE REPORT

A 25-year-old man presented with inverse hypopyon due to dense inflammatory exudation in the left eye. He was an ascetic with a history of long pilgrimages barefoot. Drainage of the pyogenic material with superficial exploration revealed localized scleral thinning at 2'o clock. Two days later, a thigh abscess was noted, which on ultrasonography showed hypoechoic areas with increased muscle mass suggestive of tropical pyomyositis. The culture from anterior chamber aspirate grew Staphylococcus aureus, as did 200 mL of pus drained from the thigh. His ocular condition improved significantly with high-dose systemic antibiotics.

COMMENTS

To our knowledge, this unusual presentation of infectious scleritis and coexistent pyomyositis has not been previously reported in the literature.

Recurrent episcleritis in children less than 5 years of age

BACKGROUND

Episcleritis, though common in adults, is a rare disease in children. Episcleritis is associated with systemic diseases in a third of cases in adults. Here we describe systemic diseases associated with recurrent episcleritis in children less than five years of age.

METHODS

This Retrospective Observational case series study was conducted at the Department of Ophthalmology of Ayub Teaching Hospital, Abbottabad, from March 1995 till February, 2006. Six children diagnosed clinically with recurrent episcleritis were included in this study. Complete ophthalmologic as well as systemic evaluation was done in each case.

RESULTS

This study was conducted on 6 children with a diagnosis of recurrent episcleritis. There were four boys and two girls, with an age range of 35-52 months. Right eye was involved in three cases, left eye in two cases while one case had a bilateral disease. Recurrence occurred in the same eye in all cases, with one bilateral involvement. Four children (66%) had a history of upper respiratory tract infection in the recent past. No other systemic abnormality was detected in any case. Two cases had a history of contact with a pet animal.

CONCLUSION

Recurrent episcleritis in young children is a benign condition. Upper respiratory tract infection is the most common systemic association. Pet animals may be a contributory factor.

Bilateral atypical nodular posterior scleritis

PURPOSE

To evaluate ocular features of nodular posterior scleritis simulating choroidal melanoma.

METHODS

A 60-year old woman presented with blurred vision in her right eye of two weeks duration. On examination she had a mild right-globe proptosis with an episcleral nodular mass as well as a large elevated nonpigmented choroidal mass involving the nasal quadrant.

RESULTS

A and B-scan ultrasonography showed a medium to high-reflective solid choroidal mass. MRI demonstrated a bi-convex mass in the medial aspect of the right globe with signal characteristics compatible with choroidal melanoma. Biopsy of the extraocular lesion demonstrated chronic inflammatory cell infiltrate suggestive of posterior scleritis. She responded to corticosteroid therapy. On evaluation 41 months later she was noted to have a similar choroidal mass in the left eye.

CONCLUSIONS

The physician should be aware of the clinical manifestations and diagnostic hall marks of nodular posterior scleritis in order to differentiate this inflammatory process from choroidal melanoma.

Steroid refractory episcleritis as early manifestation of neurosyphilis

Since the incidence of syphilis is constantly rising in western countries during the last few years the awareness of atypical presentations of this treatable disease is warranted. Especially since early treatment results in complete elimination of Treponema pallidum, thus preventing disabilities and neurological deterioration as a consequence of late stage infection. We describe a case in which a patient with asymptomatic neurosyphilis presented with a history of longstanding episcleritis. The patient was first seen in an outpatient setting, where the resistance of ocular inflammation to steroid treatment led to the uncommon diagnosis. Prolonged antibiotic treatment resulted in a complete solution of all clinical findings and a decrease of specific treponemal antibody titers. This case might serve as an example that with the recent increase in sexual transmitted diseases practitioners might be more often confronted with uncommon presentations of syphilis.