Fundus Findings

The most common fundus Þndings in posterior scleritis are choroidal folds, subretinal mass, disk edema, and macular edema. Annular ciliochoroidal detachment, serous retinal detachment, intraretinal deposits, and retinal striae may also appear. Because enucleation has been a consequence of misdiagnosis, posterior scleritis must be considered in the differential diagnosis of all these entities [1, 93, 94].

Choroidal Folds

Choroidal folds are a series of alternating light and dark lines conÞned to the posterior pole, often temporal, and rarely extending beyond the equator (Fig. 4.22). Although they are usually arranged in a horizontal and parallel pattern, surrounding a subretinal mass, they may be vertical, oblique, or irregular. Increased scleral and choroidal thickening, forcing BruchÕs membrane and retinal pigment epithelium into folds, has been proposed as a possible mechanism [95Ð98]. Because choroidal folds result in reduction of the anteroposterior diameter of the eye, they induce a relative hyperopia. Prompt recognition and treatment of the underlying cause restore visual acuity; however, prolonged choroidal folding may cause mechanical distortion of the neuroreceptors of the retina, leading to permanent loss of vision. Choroidal folds may be the only abnormal fundus Þnding in a relatively moderate posterior scleritis.

Subretinal Mass

A subretinal mass caused by a circumscribed area of scleral thickening may be detected in posterior scleritis [7, 8, 84, 86, 94]. The scleral mass has the same orange color as the adjacent normal pigment epithelium, preserves the overlying normal choroidal vascular pattern, and is frequently surrounded by choroidal folds or retinal striae [84, 86, 94]. In some cases, the surface of the mass may show scattered yellowish-white, circumscribed lesions.

Disk Edema and Macular Edema

Extension of the scleral and choroidal inßammation to the optic nerve may account for an optic

Fig. 4.22 Fundus photomicrograph of patient with posterior scleritis. Note the choroidal folds, as shown by the alternating light and dark lines

neuritis [93]. Disk edema may cause an afferent pupillary defect or visual Þeld changes, but the visual acuity is usually preserved. Extension of the scleral and choroidal inßammation with or without uveitis may cause cystoid macular edema [8]. Untreated disk edema or macular edema usually results in permanent structural damage and loss of vision. Prompt treatment of posterior scleritis may prevent this.

Annular Ciliochoroidal Detachment and Serous Retinal Detachment

Extension of the scleral inßammation into the choroid allows exudation of ßuid, which may account for an annular ciliochoroidal detachment, multiple retinal pigment epithelial detachments (Figs. 4.23 and 4.24), and/or a serous retinal detachment [93, 99]. Detachment of the peripheral choroid and ciliary body may push the lensiris diaphragm forward and precipitate an acute angle-closure glaucoma attack [100]. Subretinal ßuid in serous retinal detachment originates from choroid through multiple leaking spots in the retinal pigment epithelium. Serous retinal detachment may be conÞned to the posterior pole as a serous macular detachment or may extend or localize more peripherally as a bullous retinal detachment with shifting subretinal ßuid. In the latter, the ßuid pools inferiorly when the patient is upright and superiorly when the patient is positioned with