Tubercular Posterior Schleritis

ILMU KESEHATAN MATA LAPORAN KASUS
FAKULTAS KEDOKTERAN JULI 2020

UNIVERSITAS MUSLIM INDONESIA
TUBERCULAR POSTERIOR SCHLERITIS
INAYATUL MUTHMAINNAH
111 2019 1010
Pembimbing : dr. Marliyanti Nur Rahmah Akib, Sp.M (K), M.Kes
RUMAH SAKIT IBNU SINA MAKASSAR
PROGRAM KEPANITRAAN KLINIK
FAKULTAS KEDOKTERAN
UNIVERSITAS MUSLIM INDONESIA
2020
1
CASE REPORT
Introduction
Posterior scleritis is an uncommon and relatively unrecognized form of scleral
inflammation. It has been reported to account for 2%-12% of all cases of scleritis.
Posterior scleritis is known forits protean fundus pictures: choroidal folds orretinal
striae optic nerve head edema, circumscribed mass and exudative retinal detachment.
It is important to rule out infectious etiology in scleritis as infectious scleritis
may be clinically identical to that caused by systemic autoimmune disease.
Case Report
A 47-year-old female presented to our clinic with complaints of diminution of vision

in the left eye with ocular pain since 15 days. She consulted an ophthalmologist
locally and was on topical steroids for last 10 days. There was a history of contact
with a patient of pulmonary tuberculosis.
Eye Examination
On examination, her best corrected visual acuity (BCVA) was 6/6 in the right
eye and 6/18 in the left eye. Slit-lamp examination of the left eye showed a quiet
anterior chamber, cells in anterior vitreous. Pupils were normal and reactive in both
the eyes and colour vision with Ishihara chart was 21/21 in both eyes.
Slit-lamp and fundus examination ofthe right eye was unremarkable. Fundus
examination of the left eye showed an oedematous optic disc with surrounding
subretinal fluid and scattered multiple, discrete areas of choroiditis in mid- and
far-periphery [Fig. 1a]. Ultrasound B-scan of the left eye demonstrated
sclerochoroidal thickening with widening of sub-Tenon space with scant fluid and
elevation of optic papilla [Fig. 1b].
2
Fundus fluorescein angiography (FFA) of the left eye showed early disc staining
and peripapillary pin-head leaks in the early phase of angiogram which gradually
showed pooling around the disc in late phases [Fig. 2a and b]. Multiple patches
of choroiditis could be appreciated as early hypofluorescence and late
hyperfluorescence in FFA. Indocyanine angiography (ICG) delineated much
more areas of choroidal inflammation which were not visible clinically or in
FFA [Fig. 2c and d].
She was extensively investigated for the cause of her scleral inflammation.
Her erythrocyte sedimentation rate was elevated, and serum angiotensin
converting enzyme and serum lysozyme were within normal limits. Anti-nuclear
antibody, rheumatoid factor, anti-cytoplasmic antibodies, serologies for syphilis
were negative
Her Mantoux test was strongly positive (28 mm) and high resolution
computerised tomography (HRCT chest) revealed enlarged mediastinal lymph
nodes with apical scarring.
a. Colour fundus montage photograph of the left eye showing an oedematous

optic disc with peripapillary subretinal fluid and scattered multiple, discrete
areas of choroiditis.
3
b. Ultrasound B-scan of the left eye showing sclerochoroidal thickening,
widening of sub-Tenon space with scant fluid and elevation of optic papilla.
c. Colour fundus montage photograph of the left eye showing complete
resolution at 4-month follow-up.
d. Ultrasound B-scan of the left eye showing resolution of the inflammation
(a and b) FFA of the left eye showing early disc staining and peripapillary
pin-head leaks in the early phase of angiogram followed by pooling of the dye
around the disc in late phases. Multiple patches of choroiditis could be
appreciated as early hypofluorescence and late hyperfluorescence in the
angiogram. (c and d) Early and late phases of ICG delineated much more areas
of choroiditis.
Management
• Anti-tubercular treatment (ATT), that is, rifampicin 10 mg/kg, isoniazid 5
mg/kg, pyrazinamide 25 mg/kg and ethambutol 20 mg/kg for 9 months.
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• She was administered intravenous methylprednisolone 1 g for 3 days and
started on oral corticosteroid 60 mg/day in tapering schedule.
Evaluation
She was seen after a month, when her BCVA in left eye improved to 6/9.
Slit-lamp examination revealed a quiet anterior chamber and anterior vitreous.
Fundus examination of the left eye showed resolving optic disc edema with
surrounding subretinal fluid and choroiditis lesions.
After 4 months, her BCVA improved to 6/6. Fundus examination of the left eye
revealed complete resolution of optic disc edema, resolution of surrounding subretinal
fluid and healing of the choroidal lesions with minimal retinal pigment epithelium
hyperperturbations [Fig. 1c]. A repeat USG B-scan of the left eye demonstrated
marked reduction in sclerochoroidal thickening and resolution of the optic nerve head
[Fig. 1d]. She was advised to stop oral corticosteroid and continue ATT.
Discussion
Allergic conjunctivitis causes severe ocular discomfort, significantly reducing the

quality of life in patients. Since allergic conjunctivitis is a chronic condition, it also
has serious economic effects. Conjunctival inflammation should be well suppressed
for this reason. It is commonly treated with topical ophthalmic formulations to reduce
inflammation and to provide relief of symptoms. Topical treatments include eye
drops with antihistamines, mast cell stabilizers, non-steroidal anti-inflammatory drugs
and corticosteroids separately or combined. AC is usually accompanied by acute
manifestations and typical signs and symptoms including itching, redness and tearing,
the clinical signs and symptoms of allergic conjunctivitis, are mediated by the release
of histamine by mast cells. Posterior scleritis has plethora of presentations and
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various fundus signs has been described in patients with tuberculous posterior
scleritis.
Choroid is themost commonsite fortubercular granuloma formationineye.

Tuberculous scleritis, though extremely rare, can present with posterior scleral
involvement. In the present study, four molecules were compared with each other
and tested whether olopatadine 0.2% drop, which is a single dose instillation a day
had similar activity as that of other two dose instillation a day of antihistamine/mast
cell stabilizers drops in improving symptoms and findings. In the literature there is no
study comparing these 4 drugs in the same real-life conditions.
Conclusion
Allergic conjunctivitis is a chronic, inflammatory eye disease which significantly

affects the comfort of the patient. Olopatadine 0.1%, ketotifen 0.025% and
emedastine 0.05%, which are currently frequently used, all help to improve the
symptoms and findings of AC. In our study, we demonstrated a similar efficacy of
olopatadine 0.2% single dose instillation per day to that of other antiallergic drugs
used twice daily. The halving of the number of daily doses facilitates patients’
compliance with treatment. However, there is a need for further comparative studies
that have large participiants and have long time survey to gain a more complete
understanding of the efficacy of single daily dose olopatadine 0.2%.

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ILMU KESEHATAN MATA LAPORAN KASUS

FAKULTAS KEDOKTERAN JULI 2020

TUBERCULAR POSTERIOR SCHLERITIS

111 2019 1010

Pembimbing : dr. Marliyanti Nur Rahmah Akib, Sp.M (K), M.Kes

RUMAH SAKIT IBNU SINA MAKASSAR

PROGRAM KEPANITRAAN KLINIK

UNIVERSITAS MUSLIM INDONESIA

A 47-year-old female presented to our clinic with complaints of diminution of vision

a. Colour fundus montage photograph of the left eye showing an oedematous

Allergic conjunctivitis causes severe ocular discomfort, significantly reducing the

Choroid is themost commonsite fortubercular granuloma formationineye.

Allergic conjunctivitis is a chronic, inflammatory eye disease which significantly

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