ABSTRACT
A 56-year-old man was referred to our clinic for unilateral nodular scleritis unresponsive to systemic corticosteroids. A localized, nodular hyperemia on the nasal bulbar conjunctiva surrounding a central cyst-like lesion together with vascular engorgement was observed on slit-lamp examination of the left eye. No abnormal fundoscopic findings were noted. Surgical exploration revealed an embedded episcleral brown colored, soft to touch, splinter-like organic foreign body (FB) which was confirmed by the histopathological examination. Nodular hyperemia resolved during the postoperative follow-up period, and mild scar tissue accompanied by scleral thinning developed in the left nasal bulbar conjunctiva. Ocular injury associated with FBs may cause significant ocular morbidity depending on the nature and location of the FB. Severe visual disability may occur if left untreated. Subconjunctival FBs are rare and may present with a clinical picture mimicking episcleritis or scleritis. History of trauma involving a FB should always be assessed for an accurate differential diagnosis and appropriate management of patients with anterior scleritis.
Introduction
Ocular injury involving a foreign body (FB) may impose significant ocular morbidity and visual disability depending on the extent of the injury as well as the nature and location of the FB.1 A superficial FB in the conjunctiva or cornea can be easily detected and removed, and thus may not cause much harm if treated appropriately without delay.2 Subconjunctival FBs are relatively rare, commonly missed, and may present as FB granuloma.3 Even if they are visible, their extent in deeper tissue is difficult to assess.4
Scleritis is an inflammatory condition usually associated with systemic immunological disorders.5 Anterior scleritis may be diffuse or nodular and is characterized by pain and hyperemia. Nodular scleritis is the second most common clinical presentation of anterior scleritis, accounting for approximately 20% of cases.6 The differential diagnosis of anterior scleritis includes episcleritis and severe microbial conjunctivitis. Rarely, FB-induced episcleral granulomas can mimic nodular anterior scleritis.7
We hereby report a patient who was referred for nodular anterior scleritis unresponsive to systemic corticosteroids for 2 months who was found to have an embedded episcleral organic FB.
Discussion
Intraocular FBs may present with various clinical manifestations and affect both the anterior and posterior segments of the eye.1,8 Young male workers are the most frequently affected patient group due to work accidents.8
Detection of intrascleral/episcleral FBs may not be easy on slit-lamp examination due to the presence of a small penetrating wound covered by a large subconjunctival hemorrhage accompanied by minimal or no signs of inflammation.1 However, underlying inflammation may ensue and the patients may present with a clinical picture resembling scleritis, as in our case.
FB granuloma formation on the episcleral/scleral surface is rare. A scleritis-like clinical presentation of FBs has been previously reported in the literature. Khoo et al.7 reported a 45-year-old female who developed a suture-related granulomatous reaction related to a previous strabismus surgery and presented with a clinical manifestation of scleritis. Kapoor et al.9 also published a 36-year-old male who presented with a scleritis-like clinical presentation after a motorcycle accident. Topical and systemic corticosteroid and antibiotic treatments were not able to control inflammation; therefore, surgical intervention and FB removal were necessary in both of these cases. An intraorbital wooden FB was detected in the second case. Coelho et al.10 also reported a 76-year-old male who underwent nasal pterygium surgery and subsequently developed focal necrotizing scleritis secondary to FB entrapment under the conjunctival autograft. They treated the patient with FB removal and a conjunctival graft. Focal scleral melting continued to progress, and the patient was placed under systemic corticosteroid therapy together with an amniotic membrane graft surgery. Sen et al.11 reported a 5-year-old girl who was misdiagnosed as relapsing conjunctivitis for 1 year. During examination performed under general anesthesia, a 1.5 cm-long grass inflorescence located beneath the conjunctiva was discovered and successfully extracted.
FBs may be classified as metallic and non-metallic.12 They both possess various risks if left untreated. Iron-containing metallic FBs have been associated with ocular siderosis, while the organic subgroup of non-metallic FBs can incite acute inflammation that is likely to become chronic with serious consequences.13,14 Moreover, these organic materials encourage the growth of various microbes and can lead to severe infectious complications such as orbital cellulitis, periorbital abscess, central nervous system extension, endophthalmitis/panophthalmitis, orbitocutaneous fistula, granuloma formation, and injury to the optic nerve and extraocular muscles if left untreated.15
Episcleritis, which refers to inflammation of the superficial episcleral tissues and blood vessels, is the primary condition that needs to be differentiated from scleritis. When 2.5% topical phenylephrine is administered to the affected eye, superficial blood vessels will constrict and exhibit blanching in episcleritis, but deep hyperemia remains unaffected in scleritis.16 Upon diagnosing scleritis, a comprehensive evaluation for potential infectious and immunological factors should precede the commencement of treatment. Furthermore, as exemplified by the present case, it is important to consider the potential presence of an FB.
Whenever the diagnosis of anterior scleritis is presumed, the presence of an FB should always be ruled out for an accurate differential diagnosis and appropriate management. Surgical exploration might be necessary in addition to careful history-taking and clinical examination to detect scleral/episcleral FBs in particular.
