A 54-year-old Caucasian woman presented with a right painful ocular inflammation and progressive blurring of vision since the few preceding days. At the first visit, best corrected visual acuity (BCVA) of the right eye (RE) was 20/32 and of the left eye (LE) was 20/20. The intraocular pressure (IOP) was 32 mmHg in the RE and 16 mmHg in the left eye. On slit lamp evaluation, her right eye had marked ciliary injection, mild corneal edema with diffuse keratic precipitates, and an anterior chamber reaction (cell grade 2+, flare grade 0); on funduscopic examination there was nothing to report. The left eye was unremarkable. Based on the above clinical features, she was diagnosed with hypertensive anterior uveitis presumably caused by herpetic viral disease. Therefore, treatment with oral valacyclovir (1 g three times daily), topical dexamethasone (1 drop every two hours), topical cyclopentolate, and brinzolamide (twice daily) was prescribed and a progressive improvement of the anterior uveitis was visible.
Two months later and under treatment with oral valacyclovir (500 mg daily), her right eye developed a reddish scleral nodule at 11 o'clock (Figure 1(a)) and tenderness on palpation. At that moment, the biomicroscopy showed control of the prior uveitis, with a transparent cornea and clear anterior chamber, and the fundus remained normal. Given the anterior scleritis she started oral nonsteroidal anti-inflammatory (ibuprofen 600 mg twice daily), without effect. A complete laboratory investigation revealed a normal blood cell count, erythrocyte sedimentation rate, and angiotensin converting enzyme levels. The immunological study was negative for rheumatoid factor, antineutrophil cytoplasmic antibodies (ANCA), and antinuclear antibodies (ANA), although it was positive for HLA-B27. The infectious study, including syphilis, tuberculosis, herpes simplex, and Borrelia was negative. Therapy was changed to oral prednisolone 1 mg/Kg/day and an improvement of the scleritis occurred (Figure 1(b)); however, it remained stable for several weeks, without additional improvement. For this reason, a sample of aqueous humor was collected, in the operating room under sterile conditions, and sent for DNA virus analysis (polymerase chain reaction (PCR)) revealing VZV.
After the diagnosis of VZV infection, treatment with valacyclovir was increased (1 g three times daily) and two weeks later the patient began to decrease the oral prednisolone; however, a marked worsening of scleritis occurred with a reduction to a daily dose of 30 mg. Subsequently, weekly methotrexate 15 mg was introduced, allowing the suspension of the prednisolone, with clinical resolution of scleritis in 8 weeks (Figure 1(c)).