Fig. 7.5 Same patient as in Figs. 7.2 through 7.4, 3 months into aggressive topical and systemic antifungal therapy

Fig. 7.6 Same eye as in Figs. 7.2 through 7.4, showing the inferior scleral area, now without evidence of active scleritis

made, and the patient was treated initially with transeptal triamcinolone acetonide injection and oral prednisone 60 mg daily. The patient initially responded to treatment, and the medication was tapered. One month later, the eye suddenly became painful, with loss of vision down to light perception. Multiple scleral abscesses with necrosis and a Þbrinoid aqueous reaction were found, and ultrasonography revealed vitreous opacity. Infectious scleritis with endophthalmitis was suspected. For microbiologic studies, including aerobic and anaerobic bacteria, mycobacteria, and fungi, a scleral scrapings and cultures were obtained. Smear from scleral scraping revealed a Þlamentous fungus. The treatment included topical natamycin hourly and oral ßuconazole 100 mg daily. The necrotic sclera was debrided and subconjuntival ßuconazol was administered. However, the infection progressed to the cornea 1 week after the initiation of antifungal treatment. Cultures of the necrotic sclera showed growth of Paecilomyces in modiÞed Sabouraud agars. The treatment was switched to topical voriconazol hourly, as well as oral itraconazole 100 mg daily. Amphotericin-B 5 mg/0.1 mL was administered intracamerally once. The infection was eradicated 4 months later, but the visual acuity remained light perception.

Fig. 7.7 Same eye as in Figs. 7.2 through 7.4, showing the nasal area, again demonstrating total quiescence of the scleritic process

7.3Viral Scleritis

Viral scleritis and episcleritis are rare entities occurring either as a direct viral invasion during the course of a viral infection, or as a result of an autoimmune response to the virus, months after the initial viral encounter. The most frequent viruses that may cause scleritis are VZV, herpes simplex virus type 1 (HSV-1), and mumps.

7.3.1Herpes Scleritis

blood count, antinuclear antibody, rheumatoid factor, antineutrophil cytoplasmic autoantibody, urinalysis, and chest X-ray were within reference limits. A diagnosis of noninfectious scleritis was

7.3.1.1 Herpes Zoster Scleritis

Herpes zoster is the most common systemic infection that may involve the sclera. Herpes zoster scleritis is often progressively destructive, sometimes leading to the loss of the eye from