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Shields MK, Furtado JM, Lake SR, Smith JR. Syphilitic scleritis and episcleritis: A review. Asia Pac J Ophthalmol (Phila) 2024; 13:100073. [PMID: 38795870 DOI: 10.1016/j.apjo.2024.100073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/28/2024] Open
Abstract
Scleritis and episcleritis are rare, but potentially sight-threatening forms of syphilis. To provide a full description of this neglected subset of ocular syphilis, we evaluated the English literature for reports of syphilitic scleritis and episcleritis, recording the demographics, clinical characteristics, serological data, management practices, treatment responses, and visual outcomes. Previously published descriptions of 44 patients with syphilitic scleritis (50 eyes) and 9 patients with syphilitic episcleritis (14 eyes) were identified. The predominant type of scleritis was anterior scleritis, accounting for 92.9% of cases, with nodular anterior scleritis being the most frequent subtype at 58.1%. Almost one-quarter of patients were co-infected with human immunodeficiency virus (HIV). Initial misdiagnosis was common and led to delays in initiating treatment with appropriate antibiotics. Visual outcomes were often good in both scleritis and episcleritis, irrespective of HIV infection status, although complications including scleral thinning, keratitis, and uveitis, along with permanent visual loss and an association with neurosyphilis, were reported. Response to antibiotic treatment was typically rapid, often within 1 week. With the rising global incidence of syphilis, testing patients with scleritis or episcleritis for this infectious disease is important to ensure prompt diagnosis and treatment for best ocular and systemic outcomes.
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Affiliation(s)
- Melissa K Shields
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia.
| | - João M Furtado
- Division of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Stewart R Lake
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
| | - Justine R Smith
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia.
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Caplash S, Paez-Escamilla M, Westcott M, Dansingani KK, Indermill C, Kisma N, Frau E, Sahel JA, Bodaghi B, Jhanji V, Errera MH. Mimickers of anterior uveitis, scleritis and misdiagnoses- tips and tricks for the cornea specialist. J Ophthalmic Inflamm Infect 2024; 14:14. [PMID: 38594487 PMCID: PMC11004105 DOI: 10.1186/s12348-024-00396-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 03/29/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Anterior uveitis, inflammation of the anterior chamber and related structures, is a cohort of diseases that can present to almost any general or sub-specialty Ophthalmology practice. Its features classically involve anterior chamber cell and flare. Below the surface of these two signs exist a panoply of diagnoses. BODY: The purpose of this review is to provide a general framework for diagnoses of anterior uveitis that are often missed as well as non-uveitic pathologies that often mimic anterior uveitis. Diagnostic deviation in either direction can have vision-threatening and rarely life-threatening consequences for patients. Using a comprehensive literature review we have collected a broad spectrum of etiologies of anterior uveitis that are easily missed and non-uveitic pathologies that can masquerade as anterior uveitis. CONCLUSIONS We present a focused review on specific misdiagnosed anterior uveitis pathologies and some of the conditions that can masquerade as anterior uveitis and scleritis.
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Affiliation(s)
- Sonny Caplash
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Manuel Paez-Escamilla
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Mark Westcott
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK
| | - Kunal K Dansingani
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Chad Indermill
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Nacima Kisma
- Universite Libre de Bruxelles, Hopital Universitaire de Bruxelles, 808 route de Lennik 1170, Bruxelles, Belgium
| | - Eric Frau
- Department of Ophthalmology, Centre hospitalier National des Quinze-Vingts, Paris, France
| | - Jose-Alain Sahel
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière University Hospital, Sorbonne Universités, F-75013, Paris, France
| | - Vishal Jhanji
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Marie-Helene Errera
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA.
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Turgut F, Dingerkus V, Tappeiner C, Becker M. [Diagnostic and Therapeutic Management of Episcleritis and Scleritis]. Klin Monbl Augenheilkd 2023; 240:725-738. [PMID: 36827997 DOI: 10.1055/a-2022-0689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
While episcleritis is a benign disease only affecting the episclera, scleritis is an ocular inflammation with typically severe pain and not rarely affecting adjacent tissue.Scleritis is classified into anterior and posterior forms. Anterior scleritis is further subdivided into diffuse, nodular, necrotizing with inflammation, and necrotizing scleritis without inflammation (scleromalacia perforans). A systemic disease such as rheumatoid arthritis or granulomatosis with polyangiitis is associated with up to 50% of all patients with scleritis or episcleritis, consequently a systemic work-up with blood sampling and imaging as well as collaboration with internists are necessary.Differentiating these two entities is of high importance for planning the treatment: episcleritis has a self-limited course, whereas treatment of scleritis is obligatory to protect patients from irreversible visual loss, organ damage, and furthermore reduce the risk of mortality.Treatment depending of subtype and associated systemic disease may involve non-steroidal anti-inflammatory drugs, corticosteroids, and disease-modifying anti-rheumatic drugs.
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Turgut F, Dingerkus V, Tappeiner C, Becker M. Diagnostisches und therapeutisches Management der Episkleritis und Skleritis. AUGENHEILKUNDE UP2DATE 2023. [DOI: 10.1055/a-1956-6246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
ZusammenfassungDas schmerzhafte „rote Auge“ ist wohl das auffälligste Zeichen einer Augenerkrankung, hinter der milde, aber auch schwere Verläufe stecken können. Die Episkleritis und Skleritis sind hierbei wichtige Differenzialdiagnosen. Die rechtzeitige Diagnose ist nicht nur wichtig für die notwendige Therapie, sondern kann vor einer irreversiblen Visusminderung, einem Augenverlust sowie Organschäden schützen und ggf. sogar das Mortalitätsrisiko senken.
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Păsărică MA, Curcă PF, Dragosloveanu CDM, Tătaru CI, Manole IR, Murgoi GE, Grigorescu AC. Underlying Ciliary Body Uveal Melanoma in a Patient with Chronic Lymphocytic Leukemia Presenting for Hyphema. Diagnostics (Basel) 2022; 12:diagnostics12061312. [PMID: 35741122 PMCID: PMC9221604 DOI: 10.3390/diagnostics12061312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/16/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022] Open
Abstract
(1) Background: Ciliary body uveal melanoma is a rare subtype of uveal melanoma which comprises 3–5% of melanomas, an immunogenic cancer, and can present multifaceted initial clinical manifestations, masquerading as various ocular pathologies. Chronic lymphocytic leukemia (CLL) presents immunodeficiency and risk for the development of a secondary malignancy, with Bruton’s tyrosine kinase inhibitor treatment having a mutagenic effect and a secondary anti-platelet aggregation effect. We present the case of a 65-year-old patient undergoing treatment for CLL with ibrutinib who presented with recurrent hyphema that masked an underlying, inferiorly situated, ciliary body uveal melanoma; (2) Methods: Retrospective case review; (3) Results: An ophthalmological examination together with imaging via mode B ultrasound and contrast-enhanced magnetic resonance imaging resulted in the clinical and imagistic diagnosis of a ciliary body uveal melanoma. A pathological examination of the enucleated eye confirmed the diagnosis. Postoperative tumoral reoccurrence was not detected for 1½ years, however, CLL immunosuppression worsened with admission for severe COVID-19 disease. (4) Conclusions: CLL patient screening for melanoma should also include detailed ophthalmological examinations, which could also include ultrasound ophthalmological imaging. The avoidance of uveal melanoma metastatic disease is paramount for patient survival. CLL manifests additional profound immunosuppression.
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Affiliation(s)
- Mihai Adrian Păsărică
- Clinical Department of Ophthalmology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (M.A.P.); (C.D.M.D.); (C.I.T.); (A.C.G.)
- Department of Ophthalmology, Clinical Hospital for Ophthalmological Emergencies, 010464 Bucharest, Romania;
| | - Paul Filip Curcă
- Clinical Department of Ophthalmology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (M.A.P.); (C.D.M.D.); (C.I.T.); (A.C.G.)
- Department of Ophthalmology, Clinical Hospital for Ophthalmological Emergencies, 010464 Bucharest, Romania;
- Correspondence: ; Tel.: +40-72-015-4452
| | - Christiana Diana Maria Dragosloveanu
- Clinical Department of Ophthalmology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (M.A.P.); (C.D.M.D.); (C.I.T.); (A.C.G.)
- Department of Ophthalmology, Clinical Hospital for Ophthalmological Emergencies, 010464 Bucharest, Romania;
| | - Cătălina Ioana Tătaru
- Clinical Department of Ophthalmology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (M.A.P.); (C.D.M.D.); (C.I.T.); (A.C.G.)
- Department of Ophthalmology, Clinical Hospital for Ophthalmological Emergencies, 010464 Bucharest, Romania;
| | - Ioana Roxana Manole
- Department of Ophthalmology, Clinical Hospital for Ophthalmological Emergencies, 010464 Bucharest, Romania;
| | - Gabriela Elisabeta Murgoi
- Department of Oncology, Institute of Oncology Prof. Dr. Alexandru Trestioreanu, 022328 Bucharest, Romania;
| | - Alexandru Călin Grigorescu
- Clinical Department of Ophthalmology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (M.A.P.); (C.D.M.D.); (C.I.T.); (A.C.G.)
- Department of Oncology, Clinical Hospital of Nephrology Dr. Carol Davila, 010731 Bucharest, Romania
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Kalogeropoulos D, Katsikatsos K, Mitsis M, Kalogeropoulos C. Posterior Scleritis as a Paraneoplastic Syndrome in Colon Cancer: A Case Report. Turk J Ophthalmol 2021; 50:377-380. [PMID: 33389939 PMCID: PMC7802099 DOI: 10.4274/tjo.galenos.2020.99836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
This study presents a rare case of unilateral posterior scleritis as an ophthalmic manifestation of a paraneoplastic syndrome. A 61-year-old man presented to our department complaining of gradual worsening of vision in his left eye. Visual acuity was 10/10 and 3/10 in his right and left eye, respectively. He also mentioned that he experienced posterior ocular pain while sleeping at night, but was otherwise asymptomatic. His past ophthalmic and medical history were clear. A thorough clinical, imaging (fundus photography, optical coherence tomography, fluorescein angiography, and B-scan), and laboratory investigation was carried out. A diagnosis of posterior scleritis was made, but no obvious cause or underlying disease was identified even after a thorough systematic assessment. Regular follow-up within the next few months did not reveal any further pathological findings. Finally, 6 months after the initial presentation, the patient was diagnosed with colon cancer. Posterior scleritis can present as an ophthalmic manifestation of a paraneoplastic syndrome in patients with an underlying malignancy, even months before the presentation of systemic symptoms and diagnosis of the underlying disease. In conclusion, in patients (especially older adults) with posterior scleritis, the possibility of a malignant neoplasia must not be ignored or underestimated (paraneoplastic syndrome).
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Affiliation(s)
- Dimitrios Kalogeropoulos
- University of Ioannina School of Health Sciences Faculty of Medicine, Department of Ophthalmology, Ioannina, Greece
| | - Konstantinos Katsikatsos
- University of Ioannina School of Health Sciences Faculty of Medicine, Department of Ophthalmology, Ioannina, Greece
| | - Michail Mitsis
- University of Ioannina School of Health Sciences Faculty of Medicine, Department of Surgery, Ioannina, Greece
| | - Chris Kalogeropoulos
- University of Ioannina School of Health Sciences Faculty of Medicine, Department of Ophthalmology, Ioannina, Greece
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Dutta Majumder P, Agrawal R, McCluskey P, Biswas J. Current Approach for the Diagnosis and Management of Noninfective Scleritis. Asia Pac J Ophthalmol (Phila) 2020; 10:212-223. [PMID: 33290287 DOI: 10.1097/apo.0000000000000341] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
ABSTRACT Scleritis is a rare, vision-threatening inflammation of the sclera that is often associated with life-threatening systemic illnesses. Rheumatoid arthritis remains the most common associated systemic rheumatic disease and the commonest systemic association of scleritis. Granulomatosis with polyangiitis is the most common cause of vasculitis-associated scleritis. The etiopathogenesis of scleritis remains unclear, but can be immune complex-mediated or due to a local delayed hypersensitivity reaction. Scleritis can involve either the anterior or posterior sclera, and has a wide spectrum of clinical presentations. Among the subtypes of scleritis, necrotizing scleritis has an increased risk of complications and is more commonly associated with anterior uveitis and peripheral ulcerative keratitis. Posterior scleritis is often not diagnosed or missed due to its subtle clinical signs and protean manifestations. Meticulous history taking, detailed ocular examination, and a targeted array of investigations with a multi-disciplinary approach to find any underlying systemic disease are crucial for the management of a case of scleritis. Corticosteroids remain the mainstay of short-term treatment of scleritis; mild to moderate scleral inflammation may respond well to treatment with nonsteroidal antiinflammatory drug or topical corticosteroid. Corticosteroid-sparing immunosuppressive therapies are useful in cases with an inadequate response or failure to provide long-term control of inflammation, and to prevent recurrence of scleritis. Biologic agents are increasingly used in the management of scleritis, not responding to the conventional therapies. This review provides an overview of the various subtypes of scleritis and its systemic associations and evaluates current trends in the diagnosis and management of noninfective scleritis.
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Affiliation(s)
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
| | - Peter McCluskey
- Ocular Infections and Antimicrobials Research Group, Singapore Eye Research Institute, Singapore
| | - Jyotirmay Biswas
- Department of Uveitis and Ocular Pathology, Sankara Nethralaya, Chennai, India
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Murthy SI, Sabhapandit S, Balamurugan S, Subramaniam P, Sainz-de-la-Maza M, Agarwal M, Parvesio C. Scleritis: Differentiating infectious from non-infectious entities. Indian J Ophthalmol 2020; 68:1818-1828. [PMID: 32823398 PMCID: PMC7690484 DOI: 10.4103/ijo.ijo_2032_20] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 12/04/2022] Open
Abstract
Scleritis is a rare painful ocular disorder, associated with severe ocular pain and tissue destruction. Although a majority of these cases are immune mediated and at least half of these are associated with systemic immune-mediated diseases, a smaller minority are due to infections of the sclera. The two conditions closely mimic each other, and a thorough knowledge of the subtle differences is necessary in order to reach a timely diagnosis. Diagnostic delay can lead to a poor outcome both due to the destruction caused by the uncontrolled infection and also due to propagation of the infection with the use of corticosteroids which may have been started for presumed immune mediated scleritis. In this review, we present the clinical features, etiological agents, and the differentiating features between immune and infectious scleritis. We also present diagnostic and management guidelines for managing scleral infection.
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Affiliation(s)
| | | | - S Balamurugan
- Department of Uvea, Aravind Eye Hospital, Pondicherry, India
| | | | | | | | - Carlos Parvesio
- Consultant Ophthalmologist, Moorfields Eye Hospital, Senior Lecturer, Biomedical Research Centre, Institute of Ophthalmology UCL Moorfields Eye Hospital, London, United Kingdom
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Abstract
We report a case of a patient who presented with symptoms of acute onset scleritis in the left eye but was found to have an underlying necrotic choroidal melanoma. Asymptomatic choroidal melanoma can undergo spontaneous necrosis and manifest as severe scleritis and should be considered as an important differential.
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Affiliation(s)
- Christine A Putri
- Sheffield Ocular Oncology Service, Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, South Yorkshire
| | - Sachin M Salvi
- Sheffield Ocular Oncology Service, Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, South Yorkshire
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10
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Abstract
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.
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Affiliation(s)
- C Tappeiner
- Universitätsklinik für Augenheilkunde, Inselspital, Universität Bern, 3010, Bern, Schweiz.
- Augenabteilung am St. Franziskus Hospital, Münster, Deutschland.
| | - K Walscheid
- Augenabteilung am St. Franziskus Hospital, Münster, Deutschland
| | - A Heiligenhaus
- Augenabteilung am St. Franziskus Hospital, Münster, Deutschland
- Universität Duisburg-Essen, Essen, Deutschland
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Diogo MC, Jager MJ, Ferreira TA. CT and MR Imaging in the Diagnosis of Scleritis. AJNR Am J Neuroradiol 2016; 37:2334-2339. [PMID: 27444937 DOI: 10.3174/ajnr.a4890] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 06/14/2016] [Indexed: 11/07/2022]
Abstract
Scleritis is a rare, underdiagnosed vision-threatening condition that can occur isolated or in association with other orbital abnormalities. The etiology of scleritis is mainly inflammatory noninfectious, either idiopathic or in the context of systemic disease. Ultrasonography remains the criterion standard in diagnostic imaging of this condition but might prove insufficient, and studies on the diagnostic value of CT and MR imaging are lacking. We retrospectively analyzed 11 cases of scleritis in which CT and/or MR imaging were performed during the active phase of disease and assessed the diagnostic utility of these techniques. The most important imaging findings of scleritis were scleral enhancement, scleral thickening, and focal periscleral cellulitis. MR imaging is the recommended imaging technique, though posterior scleritis also can be accurately diagnosed on CT. It is important for the radiologist to be acquainted with these findings because being able to diagnose scleritis is of clinical significance and might be vision-saving.
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Affiliation(s)
- M C Diogo
- From the Department of Neuroradiology (M.C.D.), Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - M J Jager
- Departments of Ophthalmology (M.J.J.)
| | - T A Ferreira
- Radiology (T.A.F.), Leiden University Medical Center, Leiden, the Netherlands
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Daniel Diaz J, Sobol EK, Gritz DC. Treatment and management of scleral disorders. Surv Ophthalmol 2016; 61:702-717. [DOI: 10.1016/j.survophthal.2016.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 12/12/2022]
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Abstract
Purpose To describe a case of uveal melanoma in the peripheral choroid masquerading as chronic uveitis and to raise awareness about malignant masquerade syndromes. Case Report A 36-year-old Chinese woman presented from an outside ophthalmologist with a 6-month history of unilateral chronic uveitis unresponsive to medical therapy in the left eye. She was found to have a uveal melanoma in the retinal periphery and underwent successful enucleation of her left eye. The histopathological diagnosis confirmed the clinical diagnosis. Conclusions When uveal melanoma presents in an atypical way, the diagnosis is more difficult. This case highlights the uncommon presentations of malignant melanoma of the choroid. It provides valuable information on how peripheral uveal melanoma can present with clinical signs consistent with an anterior uveitis.
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Neoplasm Mimics of Rheumatologic Presentations: Sialadenitis, Ocular Masquerade Syndromes, Retroperitoneal Fibrosis, and Regional Pain Syndromes. Rheum Dis Clin North Am 2011; 37:623-37. [DOI: 10.1016/j.rdc.2011.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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