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    HHV-1, -2, -3: Precise medical management of herpetic nodular anterior scleritis


    Discussion and diagnosis

    Even though this patient presented with a history of floaters, previous tick bites, positive Lyme disease serology, and vitreous debris all consistent with intermediate uveitis, the presence of eye soreness with anterior segment findings should warrant early consideration of alternative diagnoses.

    Signs of scleral inflammation in the superior quadrant can be easily missed, and in these authors’ experience, are best appreciated by having the patient infraduct while the clinician lifts the upper eyelid and uses a Finnoff muscle light for examination. At this typically bright level of illumination, affected sclera is highlighted against a normal tissue background.

    While isolated intermediate uveitis typically presents with floaters in the absence of pain or redness, here the vitreous debris was likely a secondary reaction to the nodular anterior scleritis.
    By the time this patient presented to our clinic, structural damage was already present with iris thinning and posterior synechiae, probably as sequellae from anterior uveitis, found at least in 30% of cases with scleritis.1

    Topical difluprednate probably halted any anterior chamber reaction without addressing the underlying cause. The relatively higher potency (measured drug effect) of difluprednate compared with other steroid drops is more dangerous for patients already at high risk of glaucoma by inducing a steroid response via sustained elevation in IOP.

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