1. MULTI-NODULAR POSTERIOR SCLERITIS Dr Nilutpal Borah, M.S. Guwahati Eye Institute and Research Center Assam, India

2. 15 year old girl was admitted in a neurology hospital suspecting of intracranial lesion. Referred for eye examination.

3. 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.

4. 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.

5. 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

7. Fundus- OD- vitreous cells + OS- vitreous cells ++, Several small and medium, yellowish, sub- retinal mass lesions. Retinal blot hemorrhage, exudative detachment. Disc – hyperaemic & edematous

9. 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

10. 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

11. 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.

13. 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

14. B–scan showing resolution of scleritis

15. Diagnosis OS – Multinodular posterior scleritis Anterior scleritis Inflammatory optic neuritis Exudative retinal detachment

16. Treatment Intra venous methyl prednisolone -1 gm daily X 5 days Topical steroid & cycloplegic E/Drop

17. 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

18. Follow up 3 weeks – VA- 6/18p Slit-lamp and fundus examination –further improvement Treatment continued

19. 5 days after 3 wks after

20. 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.

21. 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.

22. Problems History of recurrence Effective long term prevention of recurrence in this young adult patient Role of TNF alpha i. e. infliximab, Etanercept, adalimubab in the treatment