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Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 214-216

Benefits of early treatment with intravenous methylprednisolone in recurrent posterior scleritis

Department of Ophthalmology, Yenepoya Medical College, Mangalore, Karnataka, India

Date of Web Publication11-Nov-2014

Correspondence Address:
Anupama Bappal
Department of Ophthalmology, Yenepoya Medical College, Mangalore - 575 018, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4848.144343

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The rarity and posterior location of posterior scleritis eludes diagnosis. Similarly, etiological factors of posterior scleritis could be identified in less than half of the cases. We report a case of recurrent posterior scleritis due to presumed ocular tuberculosis (TB) in an elderly lady. Complete resolution of the disease, with the combination of oral steroids, intravenous methylprednisolone, and antitubercular treatment is presented. The role of antitubercular treatment in areas where TB is endemic, even in the absence of its clear-cut evidence is emphasized.

Keywords: Anti-tubercular treatment, methylprednisolone, posterior scleritis, presumed ocular tuberculosis

How to cite this article:
Bappal A, Puthran N, Hegde V. Benefits of early treatment with intravenous methylprednisolone in recurrent posterior scleritis . Arch Med Health Sci 2014;2:214-6

How to cite this URL:
Bappal A, Puthran N, Hegde V. Benefits of early treatment with intravenous methylprednisolone in recurrent posterior scleritis . Arch Med Health Sci [serial online] 2014 [cited 2021 Jun 18];2:214-6. Available from: https://www.amhsjournal.org/text.asp?2014/2/2/214/144343

  Introduction Top

Posterior scleritis is not only rare but also eludes diagnosis because of its posterior location. Systemic inflammatory and infectious etiology can only be detected in less than 50% of the cases. The ocular features of posterior scleritis include exudative retinal detachment, choroidal detachment, subretinal fibrosis, retinal folds, choroidal folds, and macular and disc edema. [1] In vast majority of patients, early treatment with systemic steroids is quite rewarding. Intravenous methylprednisolone is a form of steroid used in the treatment of severe inflammatory eye disease. [2] Few patients may also need immunosuppressive drugs to control retinochoroidal inflammation. Addition of antitubercular treatment is indicated when there is clinical or laboratory evidence of tuberculosis (TB). [3]

  Case Report Top

A 60-year-old lady presented with complaints of decreased vision, pain, and redness in the right eye of 2 week's duration. An ophthalmologist, whom she had consulted earlier had made a diagnosis of panuveitis in the right eye and had initiated topical steroids, atropine eye drops, and antitubercular therapy (ATT), as Mantoux test was strongly positive (25 mm induration), without any visual benefit. She had experienced similar complaints in the same eye, 6 months ago, which she claimed to have resolved with some oral medications.

She had same complaints in the left eye 2 years back. The pain subsided spontaneously, but the poor vision persisted, yet no medical advice was sought. There was no history suggestive of rheumatoid arthritis, collagen vascular disease, or pulmonary TB.

Best corrected visual acuity (BCVA) was 1/60 in the right eye and 2/60 in the left eye. Intraocular pressure was 14 mmHg in each eye. Ocular movements were full but painful in the right eye. Anterior segment examination of the right eye showed engorgement of temporal conjunctival, superficial, and deep episcleral vessels. Anterior segment was unremarkable in the left eye. Posterior segment examination of the right eye showed clear media, optic disc edema, choroidal folds, localized serous retinal detachment, and peripheral shallow choroidal detachment. Posterior segment examination of the left eye showed normal optic disc and vessels. Macula showed subretinal fibrosis. A detailed systemic examination was normal.

Ocular ultrasound (B scan) of the right eye revealed increased choroidal thickness (3.8 mm), T sign due to fluid in sub-Tenon's space [Figure 1]a, disc edema, peripheral shallow choroidal detachment [Figure 1]b, and exudative retinal detachment [Figure 1]c suggestive of posterior scleritis. Blood investigation showed normal hemogram and glucose. Erythrocyte sedimentation rate was 100 mm/h. However, rheumatoid factor, antinuclear antibody (ANA) and enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) were negative. Chest X-ray was normal and sputum for acid-fast Bacilli (AFB) was negative. A diagnosis of recurrent posterior scleritis, right eye and old resolved posterior scleritis, left eye was made.
Figure 1: (a) B scan of the right eye showing increased choroidal thickness and T sign. (b) B scan of the right eye showing shallow choroidal detachment in the periphery. (c) B scan of the right eye showing localized retinal detachment

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She was started on oral prednisolone 1 mg/kg body weight under the cover of ATT, which was a combination of isoniazid 10 mg/kg body weight, rifampicin 10 mg/kg body weight, pyrazinamide 35 mg/kg body weight, and ethambutol 30 mg/kg body weight once daily. As there was no appreciable improvement clinically, 3-day course of 1 g intravenous methylprednisolone was initiated a week later. Following the third dose of intravenous methylprednisolone, vision improved to 6/24 in the right eye. Oral steroid was tapered over a period of 8 weeks. At the end of 1 month, BCVA in the right eye was 6/18, N12. Ocular ultrasound performed after 4 weeks, showed decrease in choroidal thickness and fluid in sub-Tenon's space [Figure 2]a. ATT was prescribed for 6 months. She has remained asymptomatic over a follow-up period of 6 months.
Figure 2: B scan of the right eye showing decrease in choroidal thickness

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  Discussion Top

TB is a common systemic disease in India, however ocular TB is rare. The ocular lesions could be directly caused by the mycobacterium or could be a hypersensitive manifestation to distant active or latent TB. It is important to note that in majority of patients, TB appears to have subclinical illness. The incidence of ocular TB among uveitis patients is 0.6% in India. [4] A positive Mantoux test is not a proof of active TB, but could be considered as an indirect evidence of dormant TB elsewhere. [5] Presumed ocular TB occurs frequently in the absence of respiratory symptoms and abnormal chest radiography. [6]

Posterior scleritis in this case could be a clinical manifestation of presumed ocular TB. Several reports have shown the usefulness of initiating ATT in the presence of strongly positive Mantoux, without any systemic evidence of TB, with good response to treatment. [7] ATT helps in rapid killing of the bacilli, reducing the risk of drug resistance, and preventing relapse. In our case ATT was continued for 6 months to prevent reactivation of latent TB and to prevent recurrences. A minimum of 6 months of standard ATT provides good visual outcomes in the majority of patients with presumed ocular TB. [6]

Corticosteroids have a beneficial effect on acute manifestation of inflammation. Posterior scleritis responds well to systemic nonsteroidal anti-inflammatory drugs, systemic steroids, and immunosuppressive agents. Patients with posterior scleritis need to be on long-term oral steroids or immunosuppressive drugs. Oral steroids take a longer duration for control of inflammation. Intravenous methylprednisolone is known to control the inflammation faster. [8]

Rapid response to treatment was warranted in this patient, as the left eye also had decreased vision due to previous attack of posterior scleritis, as evidenced by presence of subretinal fibrosis at the posterior pole. Good response to intravenous methylprednisolone is reported in refractory posterior scleritis and this also is known to reduce the recurrence. [9] Long-term systemic steroid therapy, 4-60 months, might cause exacerbation of active or latent TB. [10] Hence, systemic steroid should be given undercover of ATT, in patients with suspicion of latent TB.

Intravenous methylprednisolone was added, for faster control of inflammation and to prevent further structural damage, as she was a case of recurrent posterior scleritis with profound loss of vision. Response to intravenous methylprednisolone was dramatic and was followed by complete resolution of active disease within a month.

  Conclusion Top

The visual outcome in posterior scleritis is determined by the duration, severity, and recurrence of scleritis. Early introduction of methylprednisolone may reverse or mitigate the inflammatory process and therefore improve visual prognosis. The rarity and nonspecific clinical presentation of ocular TB makes its diagnosis difficult. A high index of suspicion of posterior scleritis due to presumed ocular TB is necessary to detect this potentially destructive eye disease early in its course. This report highlights the importance of treatment of recurrent posterior scleritis with oral steroid, intravenous methylprednisolone, and ATT; whenever clinically indicated.

  References Top

1.Ozdek SC, Gürelik G, Hasanreisoðlu B. An atypical posterior scleritis case: A diagnostic challenge. Retina 2001;21:371-3.  Back to cited text no. 1
2.Wakefield D, McCluskey P, Penny R. Intravenous pulse methylprednisolone therapy in severe inflammatory eye disease. Arch Ophthalmol 1986;104:847-51.  Back to cited text no. 2
3.Gupta A, Gupta V, Pandav SS, Gupta A. Posterior scleritis associated with systemic tuberculosis. Indian J Ophthalmol 2003;51:347-9.  Back to cited text no. 3
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4.Biswas J, Narain S, Das D, Ganesh SK. Pattern of uveitis in a referral uveitis clinic in India. Int Ophthalmol 1996-1997;20:223-8.  Back to cited text no. 4
5.Morimura Y, Okada AA, Kawahara S, Miyamoto Y, Kawai S, Hirakata A, et al. Tuberculin skin testing in uveitis patients and treatment of presumed intraocular tuberculosis in Japan. Ophthalmology 2002;109:851-7.  Back to cited text no. 5
6.Manousaridis K, Ong E, Stenton C, Gupta R, Browning AC, Pandit R. Clinical presentation, treatment, and outcomes in presumed intraocular tuberculosis: Experience from Newcastle upon Tyne, UK. Eye (Lond) 2013;4:480-6.  Back to cited text no. 6
7.Babu K, Satish V, Prakash O, Subbakrishna DK, Murthy KR. Role of the mantoux test and treatment with anti-tubercular therapy in a South Indian patient population of presumed intraocular tuberculosis. Ocul Immunol Inflamm 2009;5:307-11.  Back to cited text no. 7
8.Markomichelakis NN, Halkiadakis I Papaeythymiou-Orchan S, Giannakopoulos N, Ekonomopoulos N, Kouris T. Intravenous methylprednosolone therapy for acute treatment of serpiginous choroiditis. Ocul Immunol Inflamm 2006;14:29-33.  Back to cited text no. 8
9.McCluskey P, Wakefield D. Intravenous pulse methylprednisolone in scleritis. Arch Ophthalmol 1987;105:793-7.  Back to cited text no. 9
10.Pal D, Behera D, Gupta D, Aggarwal A. Tuberculosis in patients receiving prolonged treatment with oral corticosteroids for respiratory disorders. Indian J Tuberc 2002;49:83-6.  Back to cited text no. 10


  [Figure 1], [Figure 2]


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