|Year : 2023 | Volume
| Issue : 1 | Page : 48-51
Sectoral, tongue-shaped inflammatory posterior corneal stromal debris with adjacent scleritis and episcleritis of infectious etiologies
Kalpana Babu1, Kavya Nagaraj2, Vinaya Kumar Konana1
1 Department of Uvea and Ocular Inflammation, Prabha Eye Clinic and Research Centre and Vittala International Institute of Ophthalmology, Bengaluru, Karnataka, India
2 Department of Corneal Services, Prabha Eye Clinic and Research Centre and Vittala International Institute of Ophthalmology, Bengaluru, Karnataka, India
|Date of Submission||08-Aug-2022|
|Date of Acceptance||27-Sep-2022|
|Date of Web Publication||20-Jan-2023|
504, 40th Cross, Jayanagar 8th Block, Bengaluru – 560 070, Karnataka
Source of Support: None, Conflict of Interest: None
We report an interesting corneal finding of sectoral, tongue-shaped posterior corneal stromal debris with adjacent episcleral inflammation in one case and scleral inflammation in the other case. With appropriate antibiotic treatment, the stromal debris consolidated, organized, and resulted in posterior corneal stromal scarring. The etiology was Pseudomonas scleritis in the first case and Mycobacterium tuberculosis–associated episcleritis in the second case. This case report highlights an atypical corneal finding and its clinical course. The need to rule out infections as a cause in such presentations, especially in the developing world, is emphasized through this report.
Keywords: Episcleritis, Mycobacterium tuberculosis, Posterior corneal stromal debris, Pseudomonas aeruginosa, Scleritis
|How to cite this article:|
Babu K, Nagaraj K, Konana VK. Sectoral, tongue-shaped inflammatory posterior corneal stromal debris with adjacent scleritis and episcleritis of infectious etiologies. Indian J Ophthalmol Case Rep 2023;3:48-51
|How to cite this URL:|
Babu K, Nagaraj K, Konana VK. Sectoral, tongue-shaped inflammatory posterior corneal stromal debris with adjacent scleritis and episcleritis of infectious etiologies. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:48-51. Available from: https://www.ijoreports.in/text.asp?2023/3/1/48/368195
We report an interesting corneal finding of sectoral, tongue-shaped posterior corneal stromal inflammatory debris with adjacent episcleritis in one case and scleritis in the second case. Both cases were related to infection.
| Case Reports|| |
A 50-year-old male was referred to us with a history of redness, severe pain, and blurring of vision in the right eye (OD) of 15 days duration. He was started on oral steroids (60 mg/day) and topical prednisolone acetate eye drops by his ophthalmologist a week ago. There was no history of antecedent trauma or any eye surgery. Systemic history was non-contributory. On examination, his best-corrected visual acuity (BCVA) was 20/60 (OD) and 20/20 (OS). Diffuse scleritis was seen in the right eye. A temporal, tongue shaped corneal stromal haze with plenty of inflammatory debris in the mid and posterior corneal stroma was seen [Figure 1]. An area of yellowish discoloration was also seen in the nasal sclera along with restriction and pain on extraocular movements. There was minimal anterior chamber reaction. The vitreous was clear and fundus examination showed an area of peripheral choroidal detachment nasally. Left eye examination was normal. B scan showed accumulation of fluid in the suprachoroidal and sub-Tenon space and choroidal detachment. Magnetic resonance imaging (MRI) of the orbits and cranium showed enhancement of the right sclera posteriorly with normal sinuses. An incision on the nasal conjunctiva drained pus and the culture grew Pseudomonas aeruginosa. He was started on oral ciprofloxacin 750mg twice a day, topical gatifloxacin, and tobramycin eye drops. He was also started on oral and topical steroids a few days later once signs of improvement were noted. The oral steroids (40 mg/day) were continued in tapering doses along with oral ciprofloxacin 750 mg bd for nearly three months, till the scleral inflammation resolved completely. At four months follow-up, the sclera appeared thinned out 360° with greyish blue areas. The tongue-shaped, sectoral corneal haze with inflammatory debris had organized and finally resulted in stromal scarring and thinning [Figure 1]. His BCVA was 20/30 (OD) at two-year follow-up with no recurrences.
|Figure 1: Composite photograph showing right eye with diffuse scleritis (a), tongue-shaped active sectoral sclerokeratitis involving mid and posterior corneal stroma (b), posterior corneal stromal scarring with treatment on diffuse slit-lamp examination (c), and anterior segment OCT (d)|
Click here to view
A 39-year-old male presented with history of redness and discomfort in the right eye of two weeks duration and was on topical prednisolone acetate eye drops 1% four times/day. He had similar complaints two months ago which resolved with topical loteprednol etabonate eye drops 0.5%. Systemic history was not contributory. At the time of examination, his BCVA was 6/6 (OU). Slit-lamp examination of the right eye showed sectoral episcleritis involving superior and nasal areas. Tongue-shaped area of the middle and posterior corneal stromal debris adjacent to the area of episcleral congestion was noted. Corneal sensation was normal. No cells or flare were seen in the anterior chamber. Fundus examination showed few areas of retinal pigment epithelial alterations in the midperiphery. However no vitreous cells were noted. Left eye examination was normal. Anterior segment optical coherence tomography (ASOCT, Heidelberg systems) of the right eye showed hyperechoic stippled echoes in the middle and posterior corneal stroma [Figure 2]. Complete hemogram, rheumatoid factor, antinuclear antibody, anti-CCP antibodies, antineutrophil cytoplasmic antibody (pANCA and cANCA), C-Reactive protein, Mantoux, venereal disease research laboratory (VDRL), treponema hemagglutination (TPHA), serum angiotensin converting enzyme, enzyme-linked immunosorbent assay (ELISA) for HIV, liver function, and renal function tests were negative. QuantiFERON-TB Gold (QFT) test was positive. High-resolution CT (HRCT) thorax showed a few subcentimeter lymph node enlargement in the mediastinum and left hilum which could not be biopsied due to its small size. Aqueous tap for PCR was negative for herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV), Mycobacterium tuberculosis (MTB), toxoplasma, eubacterial and panfungal genomes. He received oral steroids 0.5 mg/kg bodyweight which was slowly tapered over six weeks. The episcleral inflammation resolved well while the corneal debris organized and resulted in mid and posterior corneal stromal scarring. The episcleral inflammation recurred again two weeks after stopping oral steroids. His BCVA was 6/9 (OD) and 6/6 (OS). Active multifocal choroiditis was noted in both eyes during this presentation. In view of the positive QFT test, a course of anti-tubercular therapy(Isoniazid + Rifampicin+ Pyrazinamide+Ethambutol). There were no recurrences at the last follow-up of six months. His BCVA was 6/6 (OU).
|Figure 2: Composite photograph of case 2 showing episcleral inflammation in the right eye along with adjacent tongue-shaped, active, sectoral sclerokeratitis involving posterior corneal stroma on slit-lamp examination (a) and anterior segment OCT (b); resolved episcleritis with posterior corneal stromal scarring with treatment on slit-lamp examination (c) and anterior segment OCT (d). Fundus photographs showing areas of active multifocal choroiditis (blue circles) and healing areas with treatment (yellow arrows) in both eyes (e)|
Click here to view
| Discussion|| |
A unique corneal finding of sectoral, tongue-shaped posterior corneal stromal inflammatory debris with adjacent scleritis in the first case and episcleritis in the second case have been described in this report. A probable limbitis with migration of inflammatory debris into the corneal stroma is speculated for this clinical appearance. Both the cases were associated with infection. The first case was a culture-proven P. aeruginosa while the second case was due to M. tuberculosis. Posterior corneal stromal scarring has been reported with M. tuberculosis. Viruses like HSV and VZV are also known to cause corneal involvement in the form of corneal dendrites, stromal keratitis, scarring, and endotheliitis. Other infections like syphilis and leprosy can also cause interstitial keratitis which eventually results in scarring. This report is unique for the following reasons: Firstly, this presentation highlights the clinical course of initial aggregation of inflammatory debris in the posterior corneal stroma probably as a result of the limbal inflammation due to the scleral and episcleral inflammation, followed by organization of this debris, and finally scarring in the posterior corneal stroma with treatment. This is very unique and has not been documented so far (Medline search). Secondly, this presentation as an initial manifestation of ocular tuberculosis has not been described before (Medline search). We have often seen scarring in the posterior corneal stroma in ocular tuberculosis but the development of inflammatory debris resulting in corneal scarring has not been documented (Medline search). Infections were the cause in both the cases in our series. It is only a speculation that such a presentation may be caused by an infectious etiology. Thus, it is important to rule out infections if encountered with a similar corneal presentation.
| Conclusion|| |
These 2 cases report an interesting corneal finding of sectoral, tongue shaped, posterior corneal stromal inflammatory debris associated with episcleritis and scleritis, which eventually resulted in posterior corneal stromal scarring. Such a finding should alert the ophthalmologist to rule out infection.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Murthy SI, Sabhapandit S, Balamurugan S, Subramaniam P, Sainz-de-la-Maza M, Agarwal M et al
. Scleritis: Differentiating infectious from non-infectious entities. Indian J Ophthalmol 2020;68:1818-28.
] [Full text]
Kumar DA, Agarwal A, Chandrasekar R, Chinnappan RM. Semilunar sign of cornea: A multimodal analysis of the posterior corneal opacity in non-infectious anterior scleritis. Indian J Ophthalmol 2022;70:1197-202.
] [Full text]
[Figure 1], [Figure 2]