Scleritis: Posterior

Scleritis: Posterior - Deep Trouble Defined

• Deep, boring pain, often radiating; visual loss common.
• Less common (2-12% of scleritis) but more ominous than anterior.
• Inflammation of sclera posterior to ora serrata.
• Types: Diffuse posterior, Nodular posterior.
• Systemic Associations (up to 50%):
  • Rheumatoid Arthritis (most common)
  • Granulomatosis with Polyangiitis (GPA)
  • Inflammatory Bowel Disease (IBD)
  • Systemic Lupus Erythematosus (SLE)
  • Sarcoidosis
  • Tuberculosis, Syphilis
• Diagnosis: B-scan ultrasonography (T-sign), CT/MRI.

⭐ Posterior scleritis can mimic choroidal tumors, uveal effusion syndrome, or central serous chorioretinopathy, making B-scan crucial for diagnosis (T-sign: thickened sclera + fluid in Tenon's space).

Scleritis: Posterior - Eye's Silent Scream

• Deep, boring pain (may be absent/atypical, hence "silent"), often worse at night or with eye movements; can radiate to temple/jaw.
• Symptoms: ↓ Vision (often severe), proptosis, diplopia, photophobia, headache, tenderness to palpation.
• External eye frequently appears white and quiet, unlike anterior scleritis, often delaying diagnosis.
• Key Ophthalmoscopic Signs:
  • Choroidal folds.
  • Exudative/serous retinal detachment.
  • Optic disc swelling/edema.
  • Subretinal mass or granuloma.
  • Vitreous cells.
• Investigations:
  • B-scan Ultrasound: Crucial. Shows scleral/choroidal thickening (>2mm), retrobulbar edema, classic T-sign (scleral thickening + fluid in Tenon's space).
  • CT/MRI: Orbital inflammation, scleral thickening.
• Systemic association: ~50% cases linked to autoimmune diseases (e.g., Rheumatoid Arthritis, GPA).

⭐ Posterior scleritis can masquerade as choroidal tumors, Vogt-Koyanagi-Harada (VKH) syndrome, central serous chorioretinopathy, or optic neuritis; B-scan is pivotal for differentiation.

Scleritis: Posterior - Unmasking the Culprit

• Deep, severe, boring pain, often radiating to jaw/temple; ↓ vision common.
• ~50% of cases linked to systemic autoimmune conditions (e.g., Rheumatoid Arthritis, GPA, SLE).
• Clinical Features: Often minimal external signs. May include proptosis, restricted eye movements, choroidal folds, exudative retinal detachment, optic disc edema.
• Key Investigations:
  • B-scan Ultrasound:

    ⭐ Characteristic 'T' sign: scleral/choroidal thickening + fluid in Tenon's space.

  • CT/MRI: Useful for assessing scleral thickening and extent of orbital inflammation.
• Management: Requires prompt systemic corticosteroids; immunosuppressants often needed. Essential: comprehensive systemic evaluation to identify underlying disease.

Scleritis: Posterior - Firefighting & Fallout

Treatment Ladder (Systemic Approach):

Potential Fallout (Complications):

• Exudative Retinal Detachment (RD)
• Choroidal Folds, Annular Choroidal Detachment
• Optic Disc Edema, Papillitis
• Cystoid Macular Edema (CME)
• Angle-closure Glaucoma (secondary)
• Associated Uveitis (anterior/posterior)
• Subretinal/Choroidal Neovascularization (CNV)
• Proptosis, Motility restriction
• Scleral thinning, Perforation (rare)
• Permanent Vision Loss, Phthisis

⭐ Posterior scleritis is often associated with systemic autoimmune diseases (~50% of cases), requiring rheumatological co-management.

High‑Yield Points - ⚡ Biggest Takeaways

• Posterior scleritis: severe, deep, boring pain (worse at night) and vision loss.
• Strong association (~50%) with systemic autoimmune diseases (e.g., RA, GPA).
• Key signs: choroidal folds, optic disc swelling, exudative RD, and vitritis.
• B-scan ultrasonography is crucial: shows posterior scleral wall thickening and the 'T-sign'.
• Requires systemic corticosteroids; immunosuppressants for refractory/recurrent cases.
• Consider in unexplained uveitis or orbital pain; can be misdiagnosed.