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Elderly woman presents with decreased vision and ocular pain
In the right eye, peripheral choroidal detachments were seen on dilated fundus examination.
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An 80-year-old woman presented to the anterior segment clinic with decreased vision and redness in her right eye for several days. While the onset was gradual, she began to notice a significant change in her vision within the past day. She also noted that the globe and the surrounding soft tissues were increasingly tender to touch. Ocular history was noncontributory. Medical history included hypertension and osteoporosis. The patient was taking diltiazem and ibandronate for her respective medical conditions.
| Isabel Balderas | Tom Hsu, MD |
Examination
On initial workup, the patient’s best corrected visual acuity by Snellen chart was 20/80 in the right eye and 20/40 in the left eye. IOP, pupil examination and extraocular motility exam were unremarkable. Confrontation visual fields were full.
On slit lamp examination, 2+ circumferential conjunctival injection was noted in addition to chemosis in the inferotemporal quadrant of the right eye (Figure 1). The right anterior chamber appeared narrow (confirmed with gonioscopy) with trace white blood cells. Both eyes had clear corneas with moderate nuclear sclerotic cataracts. Examination of the left eye was otherwise unremarkable.
On the posterior segment exam, 1+ anterior vitreous cell was noted in the right eye. The dilated fundus exam was notable for peripheral choroidal detachments.
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Images: Chang J, Soukiasian SH |
What is your diagnosis?
Conjunctival injection with pain
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B-scan ultrasonography was chosen to confirm and document the choroidal detachments, and the ultrasound suggested scleral thickening, although no definite T sign was seen (Figure 2). An MRI scan of the orbits with gadolinium contrast infusion was then performed, revealing inflammation of the right scleral posterior and lateral margins (Figure 3).
The patient was diagnosed with posterior scleritis causing choroidal detachments and a narrowing of the anterior chamber. The choroidal effusions were causing an anterior rotation of the ciliary body, although the patient was not in angle closure. Blood tests, including RPR, anti-nuclear antibodies, rheumatoid factor, Lyme antibodies, lysozyme and angiotensin converting enzyme levels, were negative. Other systemic workups for inflammatory conditions proved negative as well. Of interest, the patient had been on alendronate (Fosamax, Merck) in the past and recently switched to a monthly oral dosing of ibandronate (Boniva, Roche and GlaxoSmithKline) several weeks earlier. Bisphosphonates as a class have been linked with ocular inflammation including scleritis.
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Discussion
Bisphosphonates are commonly prescribed medications for postmenopausal women used to inhibit osteoclast activity and bone resorption, with the goal of maintaining or even improving bone density. Uncommonly, bisphosphonates (mostly intravenous pamidronate) have been reported to cause ocular inflammation including uveitis, episcleritis and scleritis. This is an important association to keep in mind, as the reported cases of scleritis in the literature did not resolve despite therapy until the bisphosphonate was discontinued. Some theories on the mechanism center on the stimulation of a T-cell subset by the bisphosphonates that inhibits bone resorption, but also leads to cytokine release and a pro-inflammatory cascade. Our patient has not been rechallenged with a bisphosphonate, but rechallenge would be necessary to establish a definite causal relationship.
For our patient, oral and topical steroids were started, which alleviated the pain after several days. At the same time, ibandronate was discontinued. The patient missed subsequent follow-up appointments and was not seen until 2.5 months later, completely pain-free. Best corrected visual acuity in the right eye was 20/30, anterior chambers were deep and quiet bilaterally, and there was complete resolution of the choroidal detachments in the right eye.
For more information:
- Jeffrey Chang, MD, and Sarkis H. Soukiasian, MD, can be reached at Lahey Clinic, 41 Mall Road, Burlington, MA 01805; 781-744-5100; Web site: www.lahey.org.
- Edited by Isabel M. Balderas, MD, and Tom Hsu, MD. Drs. Balderas and Hsu can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com. Drs. Balderas and Hsu have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.
References:
- Fraunfelder FW, Fraunfelder FT. Bisphosphonates and ocular inflammation. N Engl J Med. 2003;348(12):1187-1188.
- Leung S, Ashar BH, Miller RG. Bisphosphonate-associated scleritis: a case report and review. South Med J. 2005;98(7):733-735.
- Mbekeani JN, Slamovits TL, Schwartz BH, Sauer HL. Ocular inflammation associated with alendronate therapy. Arch Ophthalmol. 1999;117(6):837-838.