Photographs of the right eye of a previously healthy 45-year-old man who presented with bilateral finger-counting visual acuity, necrotizing scleritis, and anterior uveitis. Workup revealed positive c-ANCA and microhematuria suggestive of systemic vasculitis. a. The patient upon presentation. b. The patient 2 weeks after initial therapy with pulsed IV corticosteroids followed by 60 mg of prednisone and 150 mg of cyclophosphamide daily. Inflammation has been completely suppressed and visual acuity is 20/40. It is noteworthy that patients with c-ANCA positive scleritis, even in the absence of other evidence of systemic vasculitis, are more likely to have difficult-to-control disease and commonly require IMT for proper disease control.