Posterior Scleritis in a Patient with Psoriasis Masquerading as Acute Angle Closure Glaucoma

Abstract

Posterior scleritis is a relatively uncommon form of scleral inflammation of the posterior segment of the eye. Clinical manifestations include ocular pain, headache, pain with ocular movements, and loss of vision. A rare presentation of the disease is acute angle closure crisis (AACC) with elevated intraocular pressure (IOP) secondary to anterior displacement of the ciliary body. Various systemic diseases have been described to co-exist with posterior scleritis; however, psoriasis has not been associated with posterior scleritis. Here, we present a case of posterior scleritis which initially presented as AACC in a patient with pre-existing psoriasis. A 50-year-old male with a history of psoriasis under treatment presented to the emergency department with intense sudden ocular pain and loss of vision on the left eye as well as headache and nausea. A thorough medical and ocular history was taken, and a detailed examination of the anterior and posterior segment was completed including visual acuity and IOP. Initial diagnosis of AACC was made, and appropriate actions were taken with partial resolution of his symptoms. However, upon further work-up including ultrasound (B-scan) of the left eye a final diagnosis of posterior scleritis was made. The patient was treated with steroids and nonsteroidal anti-inflammatory drugs which dramatically improved his condition. Photographic evidence of initial presentation and post-treatment condition was obtained and presented in this report. Posterior scleritis is a potentially vision-threatening condition which is usually challenging to diagnose. In this report, we highlight the challenges one might come into when dealing with different manifestations of the same disease, increasing awareness. This case of posterior scleritis presenting as AACC in a patient with a history of psoriasis enhances what we already know from the literature as well as provides some new insights in the clinical manifestations of posterior scleritis in the setting of psoriasis without arthritis.

Posterior Scleritis: A Case Report and Literature Review of the Management of the Condition

“…It is usually unilateral but rarely can affect both eyes in up to a third of cases [ 4 ]. Symptoms of posterior scleritis include eye pain, headache, pain with ocular movements, and loss of vision if not treated timely [ 1 ]. Clinical signs are nonspecific and include conjunctival chemosis, hyperemia, and optic nerve swelling [ 5 ].…”

“…About one-third of cases are binocular, making bilateral disease even rarer [ 4 ]. Symptoms usually include ocular pain, which is exacerbated by ocular movements, headache, and loss of vision [ 1 ]. It is often misdiagnosed and potentially sight-threatening because of its non-specific presentation; a high index of suspicion and expertise are needed for diagnosis [ 2 ].…”

“…It is often misdiagnosed and potentially sight-threatening because of its non-specific presentation; a high index of suspicion and expertise are needed for diagnosis [ 2 ]. Posterior scleritis is commonly associated with rheumatic diseases, such as rheumatoid arthritis (RA), anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis, and systemic erythematous lupus (SLE) [ 1 ]. Scleral thickness can be measured with B-scan ultrasonography with high sensitivity and specificity and is the gold standard test for diagnosing posterior scleritis [ 5 ].…”

Necrotizing Anterior Scleritis with kertouveitis in a Patient with Psoriasis: A Case Report

“…Many cases of posterior scleritis associated with psoriasis and psoriatic arthritis (PsA) have been reported; however, data on anterior necrotizing scleritis with in ammation are limited [5]. Therefore, we present a rare case of necrotizing anterior scleritis with keratouveitis during a are-up of psoriasis and emphasize the importance of timely intervention to avoid sight-threatening complications.…”

“…Ocular psoriasis commonly manifests as blepharitis, dry eye, conjunctivitis, or uveitis. Ocular manifestations occur in 10 to 12% of patients with psoriasis, whereas its occurrence in psoriatic arthritis (PsA) is higher at 31%; however, Chandran et al and Cruz et al have reported higher rates of 65% and 81.4%, respectively [1,5]. Ocular symptoms often develop in men during acute exacerbations of psoriasis, with a reported latency period of more than ve years [1,2,4].…”