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Table 2 Differential diagnosis of posterior scleritis

From: Choroidal involvement in non-infectious posterior scleritis

  Posterior scleritis Central serous chorioretinopathy (CSC) [15, 40] Vogt-Koyanagi-Harada disease (VKH) [15, 40, 41] Choroidal melanomaa [13, 40]
Typical clinical characteristics
Laterality Mostly unilateral Unilateral or bilateral Bilateral (second eye involvement within 2 weeks) Unilateral
Presenting symptoms Acute painful vision loss (typically worse at night or on eye movements) Painless vision loss Blurred vision, photophobia, ocular pain. Associated systemic symptoms depending on disease stage. Painless visual changes (rarely painful when necrotic). Can be asymptomatic.
Associated clinical signs Anterior scleritis, anterior uveitis, vitreous inflammation, choroidal folds, optic disc edema. Round/oval serous retinal detachment with or without detachment of retinal pigment epithelium (RPE), RPE changes (focal or multifocal).
No associated inflammatory signs.
Granulomatous anterior uveitis, vitritis, diffuse choroiditis, Dalen-Fuchs nodules, sunset glow fundus, optic disc edema.
Frequent associated skin changes, CNS findings (incl. Cerebrospinal fluid pleocytosis)
Pigmented or amelanotic elevated choroidal mass, lipofuscin often present. Serous RD and/or sentinel vessel possible. Associated inflammation rare.
Response to steroids Improvement of pain and imaging findings Can worsen presenting signs and symptoms Improvement of pain and imaging findings None
Multimodal imaging findings
B-scan ultrasound T-sign, increased thickness of the posterior coats (> 2.0 mm), nodular subtype possible (sessile or dome shaped lesion with high internal reflectivity) Serous RD possible Serous RD possible Dome-shaped or mushroom-shaped choroidal lesion with typically low to medium internal reflectivity. Choroidal excavation and serous RD possible.
OCT Choroidal folds, serous retinal detachment, macular oedema Subretinal fluid (SRF) (can be multifocal), RPE-detachment(s), intraretinal fluid (IRF) possible, atrophic RPE-changes possible Serous retinal detachment with typical fibrinous septa Dome-shaped solid choroidal mass, accompanying SRF possible
EDI-OCT Localized choroidal thickening in affected eye in acute stages, choroidal thinning after treatment or in advanced stages Diffuse choroidal thickening, dilated large vessels in Haller’s layer with thinning of overlying smaller vessels in Sattler’s layer and choriocapillaris Choroidal thickening in acute stages, choroidal thinning after treatment or in advanced stages Dome-shaped solid choroidal mass with smooth surface
FA Early pinpoint leaks with late pooling in cases with subretinal fluid Focal leak in acute phase (typically described as ‘ink blot’ or ‘smokestack’ leakage pattern). Multifocal leakage (‘hot spots’) and pooling under detached RPE possible. Disc leak absent. Focal areas of delayed choroidal perfusion, multiple pinpoint regions of leakage at the RPE-level, disc hyperfluorescence Multiple areas of pinpoint leakage
ICGA Choroidal vasculitis, zonal choroidal hyperfluorescence (± pinpoint leakage), choroidal perfusion delay, enlargement of draining choroidal veins, and hypofluorescent dark dots Early phase: large, dilated, densely packed choroidal vessels. Mid-to late-phase: choroidal vascular hyperpermeability (focal or multifocal hyperfluorescent staining with indistinct borders). Early phase: hyperfluorescence. Early-to-mid-phase: hypofluorescence. Mixed pattern of fluorescence, blockage of fluorescence in pigmented lesions
  1. aChoroidal melanoma serves as an example of choroidal malignancies in this table. Other tumors such as metastatic deposits or choroidal lymphoma have different clinical and imaging characteristic and should also be borne in mind