This case demonstrates many important points about the presentation, evaluation, and management of patients with nodular anterior scleritis. Examination of the superior sclera with a muscle light and lid elevation can help with proper diagnosis. The presence of transillumination defects of the iris in the setting of ocular inï¬ammation should raise clinical suspicion of a herpetic cause.
Utility of serologic testing can be limiting or even misleading, and in the right clinical context (such as previously failed targeted treatment), may warrant a more precise diagnostic approach (such as aqueous biopsy with PCR testing).
Careful discretion of steroid drops should be considered with regard to risk of IOP elevation.
Finally, this case also highlights that misdiagnosis may perpetuate disease by promoting HHV replication in the setting of immunosuppression without concomitant anti-herpetic viral suppression.
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