Immune recovery posterior scleritis in a HIV positive patien
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A 37-year-old woman with history of ocular and periocular pain in the left eye, irradiating to the ipsilateral forehead, and decreased vision with a central scotoma. Her best-corrected visual acuity (BCVA) was 20/20 (OD) and 20/67 (OS), with intraocular pressure (IOP) of 11 mmHg (OD) and 8 mmHg (OS). Anterior segment examination of the left eye revealed severe chemosis, subconjunctival hemorrhage. Fundus examination showed the disc edema and retinochoroidal folds. B-ultrasound and optical coherence tomography (OCT) revealed retrobulbar edema with typical “T” sign and exudative retinal detachment, suggesting posterior scleritis.

She was under consistent HAART for 3 years, during which her CD4 counts significantly peaked from 103 cells/µL to 432 cells/µL. When she presented to the hospital with severe posterior scleritis, the CD4 count has further elevated to 698 cells/µL (normal range 400–1300 cells/µL) and the HIV viral load was tested below the detection level.

The patient was subconjunctivally injected with Triamcinolone (1 mg) at outpatient service immediately but showed no signs of improvement. One week later, she underwent a diagnostic pars plana vitrectomy to rule out infectious etiology, with an intravitreal injection of 4 mg Triamcinolone. Molecular analysis of vitreous aspirate detected low titer of Aspergillus sydowii DNA but was neglected as the patient did not show symptoms of endophthalmitis, which was presumed as a non-viable infection. After vitrectomy, topical 0.1% Dexamethasone eyedrops four times daily and ointment every night was prescribed. Surprisingly, within 5 days her vision improved. Since the patient showed an excellent therapeutic response, the topical 0.1% Dexamethasone eye drops and ointment was continued for 6 months. Then the follow-up BCVA was 20/20, the retrobulbar inflammation subsided, B-ultrasound showed mild edema.