Posterior nodular scleritis associated with presumed ocular tuberculosis: two case reports

Abstract

Introduction: Posterior nodular scleritis is an uncommon form of scleral inflammation that represents a diagnostic challenge, as it mimics malignant lesions, potentially leading to misdiagnosis and inadequate treatment. Methodology: Two case reports of posterior nodular scleritis, focusing on its clinical characteristics and multimodal evaluation. Results: Case 1 describes a 40-year-old woman with visual scotoma, headache, and periocular pain in the left eye for 2 weeks, presenting with whitish subretinal lesions and macular elevation on the fundoscopic exam. Ultrasound revealed temporal parietal nodular thickening with subretinal and subtenon fluid compatible with posterior nodular scleritis. Etiological investigation revealed a positive tuberculin skin test with a normal chest CT scan, and specific antituberculosis treatment was instituted in conjunction with systemic corticosteroid therapy. The patient progressed with complete regression of the lesions and preservation of vision. Case report 2 describes a 56-year-old diabetic woman with progressive visual loss and pain in her left eye for 2 months. Anterior biomicroscopy revealed conjunctival hyperemia, granulomatous keratic precipitates, and cataract, while fundoscopy showed proliferative diabetic retinopathy. Ultrasound revealed superior nasal nodular thickening and diffuse subtenon fluid. Etiological investigation showed a positive tuberculin skin test with a normal chest CT scan, and she received antituberculosis and anti-inflammatory therapy. Despite therapy, she developed macular atrophy with permanent visual impairment. Discussion: Both cases represent posterior nodular scleritis associated with presumed ocular tuberculosis. The presumptive diagnosis of ocular tuberculosis was based on a triad of compatible clinical-radiological findings, a positive tuberculin skin test, and a favorable response to treatment. Multimodal evaluation including B-scan ultrasound was essential for differential diagnosis with intraocular tumors. Combined treatment proved effectiveness in controlling inflammation in both cases. Conclusion: Recognizing ocular tuberculosis as the etiology of posterior nodular scleritis is essential in endemic settings, particularly where there is a positive tuberculin skin test and compatible clinical and radiological findings. Multimodal evaluation including ocular ultrasound allows for accurate diagnosis and differentiation from tumorous lesions. Visual prognosis remains variable depending on early diagnosis and severity of initial inflammation, reinforcing the importance of timely detection and treatment.