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Last Month’s Blink

Nodular Posterior Scleritis

Written by Michael T. Andreoli, MD, Northwestern Medicine, Naperville, Ill. Photos by George Henry, CRA, PBT (ASCP), Wheaton Eye Clinic, Wheaton, Ill.

A 45-year-old woman with a history of breast and thyroid cancer presented with an acute decline of vision in her left eye. A prior orbital computed tomography (CT) scan had been completed in the emergency room, with a report of a “mass suspicious for metasta­sis.” Visual acuity was 20/20 in her right eye and 20/200 in her left. The anterior segment exam demonstrated mild conjunctival chemosis. The dilated fundus exam revealed a choroidal eleva­tion in the macula with overlying subretinal fluid (Fig. 1). Ultrasound revealed a choroidal lesion with medium-to-high internal reflectivity (Fig. 2). OCT showed a choroidal elevation with overlying subretinal fluid (Fig. 3A).

CT of the chest, abdomen, and pelvis was performed to rule out cancer progression. Despite the patient’s strong cancer history, the clinical appearance and associated conjunctival chemosis suggested a possible inflammatory etiology. Oral prednisone (60 mg/day) was initiated, and the subretinal fluid and choroidal elevation resolved in one week (Fig. 3B), suggesting a diagnosis of giant nodular scleritis mimicking choroidal metastasis. The subretinal fluid recurred during prednisone taper, and the patient was later started on methotrexate with excellent long-term stability, regaining 20/20 vision.

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