_scleritis a diagnostic dilemma后巩膜炎诊断困境课件

MULTI-NODULAR POSTERIOR SCLERITIS Dr Nilutpal Borah, M.S. Guwahati Eye Institute and Research Center Assam , India 15 year old girl was admitted in a neurology hospital suspecting of intracranial lesion. Referred for eye examination. Ocular history OS 1 week- sudden , complete, painful loss of vision with swelling. Pain around the left periorbital region, radiating towards left hemicranium, left ear and left side of the neck. Nausea and vomiting . Past history 5 months ago- OS pain, redness, dimness of vision. Treatment was incomplete. 1 year ago- OD - similar episode of pain & redness. No treatment . Clinical findings Tender globe VA -OD 6/6, OS PL negative (max illumination with IDO) OS - RAPD + Lids swollen, mild superior conjunctival and episcleral congestion. flare +, cell+ , fibrinous deposition on crystalline lens Fundus- OD- vitreous cells + OS- vitreous cells +, Several small and medium, yellowish, sub- retinal mass lesions. Retinal blot hemorrhage, exudative detachment. Disc hyperaemic & edematous Investigations Blood R/E - ESR 40 mm(1st hr) Hb 9.0% Urine R/E - Albumin trace Pus cell 2-4/HPF Epithelial cells 1-2/HPF Investigations Systemic examinations - unremarkable. Paranasal sinuses - normal CT Scan brain - normal X - ray -chest - normal Stool R/E - ova & cysts- absent Montoux test - negative VDRL - non-reactive ANA -negative HIV - negative Retrovirus/HBsAg - negative FFA Early phase- multiple, irregular blocked fluorecscent spots with focal hyperfluorescence at the margins. Late phase - pooling of dye with minimal staining . Paravascular leakage. Disc - diffuse hyperfluorescence . B-scan ultrasonography Multiple, irregular mass lesions involving choroid and sclera. Moderate to high internal reflectivity. Choroid and sclera grossly thickened Peribulber edema - present T sign- positive Bscan showing resolution of scleritis Diagnosis OS Multinodular posterior scleritis Anterior scleritis Inflammatory optic neuritis Exudative retinal detachment Treatment Intra venous methyl prednisolone -1 gm daily X 5 days Topical steroid & cycloplegic E/Drop Follow up 5 th day VA FC- 1 meter Slit-lamp and fundus examination showed improvement Treatment continued with - Oral steroids(1mg/kg ), topical steroid eye drop Follow up 3 weeks VA- 6/18p Slit-lamp and fundus examination further improvement Treatment continued 5 days after 3 wks after Discussion Scleritis- inflammatory condition, characterized by edema and inflammatory cell infiltration of sclera. More common in woman of 50-60 years. 50% cases are associated with systemic diseases. Conclusion Multinodular posterior scleritis is a rare disease. Varied mode of presentation may complicate diagnosis. Posterior scleritis in this young female patient responded well to I.V.methyl prednisolone and oral steroid. Problems History of recurrence