Case report: Woman presents with posterior scleritis

Posterior scleritis continues to be the prominent differential diagnosis of subretinal and choroidal swellings. Therefore, it is imperative to know that it can present clinically as exudative retinal detachment, proptosis, disc edema, choroidal folds, subretinal mass, myositis and rarely glaucoma, periorbital edema, chemosis and conjunctival injection. It is mostly found in women older than 40 years of age. In this case report, we present the clinical diagnosis and management of an isolated case of posterior scleritis.A 45-year-old healthy woman presented with pain, redness and photophobia in the left eye for 12 days’ duration. She had no relevant ocular history. Her best corrected visual acuity was 20/50 in both eyes. On slit lamp examination, there was mild anterior chamber reaction and a relative afferent pupillary defect (Figure 1) in the left eye while the right eye was normal. She had grade 2 nuclear sclerosis in the lens of both eyes. Color vision was minimally affected in the left eye and normal in the right eye. Fundus evaluation showed a large subretinal elevation underlying the optic disc area, causing optic disc edema (Figure 2) with flame-shaped hemorrhages and choroidal folds stopping short of the macula. Ultrasound B-scan showed a diffuse subretinal mass (Figure 3) with no pathognomonic “T sign.” MRI of the orbit with contrast revealed an irregular choroidal mass with inhomogeneous enhancement with no conclusive diagnosis. Routine investigations such as CBC, ESR, serum urea, creatinine, random blood sugar, liver function tests and chest X-ray were performed. All blood investigations were within normal limits, but Mantoux test was borderline. With choroidal melanoma as our provisional diagnosis, fundus fluorescein angiography did not show dual circulation. Interestingly, B-scan at 1 week after initial presentation showed choroidal thickening and fluid in the Tenon’s space as early T sign (Figure 3). Automated perimetry showed a temporal field defect in the affected eye.