There’s more than meets the eye: Posterior pole conundrum

There’s more than meets the eye: Posterior pole conundrum | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report There’s more than meets the eye: Posterior pole conundrum Isha Agarwal, Anju Bansal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6899254/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Purpose To report the clinical features and management using multimodal imaging of optic neuritis and branch retinal artery occlusion (BRAO) associated with posterior scleritis. Methods A 41-year-old male, recently diagnosed with hypertension, presented with sudden onset diminution of vision with painful eye movements. Patient underwent complete ophthalmic evaluation with systemic evaluation Results Early diagnosis led to improvement in BCVA at presentation from counting fingers at 1 metre to 20/80 at 5 month follow up with resolution of subretinal fluid clinically. Conclusion Early and prompt diagnosis can prevent from irreversible vision loss due to optic neuritis and BRAO secondary to posterior scleritis. BRAO Oral Steroids Posterior scleritis SRF Sub-tenon fluid Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Summary Posterior scleritis can involve optic nerve and retinal vessels causing optic neuritis and retinal artery occlusion further affecting the visual prognosis. A clinician should have a high index of suspicion for diagnosing posterior scleritis which can be a great mimicker. Timely management can save vision in such patients. Introduction Inflammatory conditions may cause vascular complications in the form of retinal haemorrhages, retinal vascular hyperpermeability, retinal vascular occlusion, macroaneurysms, retinal or choroidal neovascularization, and retinochoroidal anastomosis 1 – 2 . Though involvement of artery is rare, but few cases have been reported. We report a case of optic neuritis with branch retinal artery occlusion secondary to posterior scleritis. Case Report A 41-year-old male presented with chief complaints of sudden diminution of vision after waking up in morning in left eye for past one month with painful ocular movements with a systemic history of a recent diagnosis of hypertension but not on any anti-hypertensive medications. Patient does not give any history of similar episode in the past or in any other family member. There is no history of trauma, involvement of skin, or joint pain correlating with any systemic involvement. On ophthalmic examination, the best corrected visual acuity (BCVA) was 20/20 in right eye and counting fingers at 1 metre in left eye. Intraocular pressure (IOP) in both eyes was normal, anterior segment examination was unremarkable except afferent pupillary defect in the left eye. Fundus examination was normal in the right eye and the left eye revealed a clear media with optic disc edema, multiple superficial retinal haemorrhages in temporal peripapillary region with an area of retinal whitening over macula infero-temporally with a large pocket of sub-retinal fluid (SRF) just superior to macula (Fig. 1 a and 1 b). Patient was subjected to a battery of ocular investigations. Optical Coherence tomography (OCT) was normal in right eye; however, the left eye revealed an elevated foveal contour with hyperreflectivity of inner retinal layers, a neurosensory detachment superior to macula involving fovea, intra-retinal hypo-reflective cystic spaces in inner retinal layers and an underlying choroidal mound (Fig. 1 c, 1 d and 1 e). Ultrasonography of the left eye showed a shallow elevation at the optic nerve head (ONH) with a hyper-echoic membranous echo arising from ONH and extending inferiorly till posterior pole with grossly increased retino-choroidal complex thickness and with sub-tenon’s fluid (Fig. 2 a). Fundus auto-fluorescence (FAF) revealed hyper autofluorescence in the areas of fluid accumulation and speckled autofluorescence over the macular area (Fig. 2 b). On evaluation, patient’s blood pressure was raised to 138/102 mmHg. After systemic investigations which were normal except slightly elevated serum homocysteine levels, both eyes fundus fluorescein angiography was done which revealed grossly delayed arterio-venous transit phase along with a blocked fluorescence in the region of infero-temporal macular branch retinal artery in left eye, along with blocked fluorescence around the disc corresponding to the disc edema. Late phase angiography depicted disc leakage, along with pooling of dye in serous retinal detachment involving macula and just superior to macula with multiple pin point leakages temporal to disc (Fig. 3 ). Provisional diagnosis of optic neuritis with branch retinal artery occlusion (BRAO) secondary to posterior scleritis was made. After physician review and ruling out all infectious causes, oral steroids (1mg/kg/day in tapering dose) were started. On subsequent visits, patient was symptomatically better with a marked reduction in ocular pain as well as a subjective and objective improvement in vision. On serial fundus examination, there was resolving disc edema, disc haemorrhages, reduction in retinal edema and whitening secondary to BRAO and a resolving pocket of SRF (Figs. 4 and 5 ). On his last visit after 5 months, his BCVA was 20/20 in the right eye and improved to 20/80 in the left eye. IOP was normal in both eyes. Fundus examination of the left eye revealed a clear media, mild disc pallor with foveal thinning with resolved disc haemorrhages, resolved retinal whitening secondary to BRAO and SRF clinically as well as on OCT (Fig. 6 ). Discussion Scleritis is primarily immune-mediated vasculitis due to antigen-specific T-cell activation and immune complex deposition. Posterior scleral inflammation can involve optic nerve and retinal vessels, resulting in vascular occlusions 3 . Cilioretinal artery occlusion, retinochoroidal infarction, and combined retinal vascular occlusion have been reported 4 – 6 . Several mechanisms have been described in literature which led to the development of BRAO secondary to posterior uveitis. BRAO happens at the site of an active focus of retinitis or retinochoroiditis. It could be due to a direct compression by foci of retinitis or chorioretinitis causing interruption of the blood flow. Arterial occlusion may also occur due to arteriolar contraction resulting from increased blood viscosity and inhibition of coagulation due to heparin release from the mast cells in response to an acute inflammatory stimulus 7 . Another mechanism could be perivasculitis from the infiltration of the vessel wall by the inflammatory cells, which may lead its thickening and hence, disruption of blood flow and arterial thrombosis 8 . Brown et al 9 has reported an 81% prevalence of rubeosis iridis (mean time was 11.8 weeks) and neovascular glaucoma in patients with BRAO secondary to posterior scleritis. At the last follow-up at 5 months, our patient did not have any such complication as mentioned above. Multimodal imaging is the key to diagnosis in such cases with atypical presentations. In addition, a strong index of clinical suspicion is needed for clinching the diagnosis and the right management of such patients. Conclusion Early and appropriate treatment with oral steroids in inflammatory conditions may help induce prompt resolution of the ocular inflammation and reperfusion of the occluded artery and improve visual outcome as seen in our case. Limitation Due to rarity of this ophthalmic condition, more cases need to be studied in detail to review varied atypical presentation and complications. Declarations Ethics approval and consent to participate: Taken Consent for publication: Taken Availability of data and materials: Not Applicable Competing interests: No interest Funding: Not Applicable Acknowledgements: Not Applicable Consent from Parents: Signed informed consent obtained for publishing the data Authors' contributions: Dr Isha Agarwal.: report writing, Data collection, report editing. Dr Anju Bansal : Case report writing, Data Collection References Brézin AP (2012) Uveitis. Presse Med 41:10–20 Yamanaka E, Ohguro N, Kubota A et al (2004) Features of retinal arterial macroaneurysms in patients with uveitis. Br J Ophthalmol 88:884–886 Wilhelmus KR, Grierson I, Watson PG. Histopathologic and clinical associations of scleritis and glaucoma. Am J Ophthalmol 1981; 91: 697–705. Shukla D, Chandramohan K, Rao N et al. Posterior scleritis causing combined central retinal artery and vein occlusion. Retina 2004; 24: 467–469. Sahu DK, Rawoof AB. Cilioretinal artery occlusion in posterior scleritis. Retina 2000; 20: 303–305. Frost AN, Sparrow JM, Rosenthal AR. Posterior scleritis with retinal vasculitis and choroidal and retinal infarction. Br J Ophthalmol 1994; 78: 410–412. Braunstein RA, Gass JDM (1980) Branch artery obstruction caused by toxoplasmosis. Arch Ophthalmol 98:512–513 Ormerod LD, Skolnick KA, Menosky MM et al (1998) Retinal and choroidal manifestations of cat-scratch disease. Ophthalmology 105:1024–1031 Brown GC, Duker JS, Lehman R, et al. Combined central retinal artery–central vein obstruction. Int Ophthalmol 1993;17:9–17. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 21 Jul, 2025 Reviews received at journal 19 Jul, 2025 Reviews received at journal 18 Jul, 2025 Reviewers agreed at journal 14 Jul, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviewers agreed at journal 12 Jul, 2025 Reviewers agreed at journal 12 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers invited by journal 09 Jul, 2025 Editor assigned by journal 09 Jul, 2025 Editor invited by journal 08 Jul, 2025 Submission checks completed at journal 07 Jul, 2025 First submitted to journal 07 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6899254","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":484587356,"identity":"3c0e3585-7d71-4497-a79b-99a00f5b24e2","order_by":0,"name":"Isha Agarwal","email":"","orcid":"","institution":"Dr Shroff Charity Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Isha","middleName":"","lastName":"Agarwal","suffix":""},{"id":484587357,"identity":"f02bdb76-d6da-4f5e-8d81-aa45ccd315f0","order_by":1,"name":"Anju Bansal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIiWNgGAWjYBACAzBZACIOMBz4UMEmB2Y+IKgFTB5gPDjjDJ8xmJlAnBYG5sO8bXKJDSAmPi3m7GcPf/hhwCBvznjGAKjFLH1+2OGHQFvs5HQbsGux7MlLk+wxYDDc2XDG4OCcc2m5G2+nGQC1JBubHcDhsAM5Zgw8BgyMGw6cMTjwpuxY7sbZCSAtBxK34dJy/o3xxz8GDPZgLTxs/9MNZ6d/wK/lRo6BNNCWRJCWgzxtbAny0jn4bbGc8cZMWsZAInnDgWMFwEBmM9wgnVNwIMEAt1/M+XOMP76psLHdcOPw5g/AqJSXn50OYtjJ4dICBRJAdAAWIGASr3Io4G+A0PINxKgeBaNgFIyCkQQAvhFrB5QDq5QAAAAASUVORK5CYII=","orcid":"","institution":"Dr Shroff Charity Eye Hospital","correspondingAuthor":true,"prefix":"","firstName":"Anju","middleName":"","lastName":"Bansal","suffix":""}],"badges":[],"createdAt":"2025-06-15 15:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6899254/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6899254/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86758182,"identity":"a056d674-107e-45e6-8e2c-8de51cdd01fd","added_by":"auto","created_at":"2025-07-15 09:49:38","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":303280,"visible":true,"origin":"","legend":"\u003cp\u003e1a) Colour Fundus photograph of right eye showing normal fundus\u003c/p\u003e\n\u003cp\u003e1b) Colour Fundus photograph of left eye at presentation with disc edema, flame shaped haemorrhages and fluid pocket in peripapillary region and supero-temporal to macula and retinal whitening along the infero-temporal branch of retinal artery.\u003c/p\u003e\n\u003cp\u003e1c) Right eye macular OCT depicting normal foveal contour with normal retinal layers integrity.\u003c/p\u003e\n\u003cp\u003e1d) Left eye macular OCT depicting bacillary layer detachment with choroidal elevation.\u003c/p\u003e\n\u003cp\u003e1e) Left eye OCT through infero-temporal quadrant showing inner layer hyper-reflectivity with bacillary layer detachment with choroidal elevation.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6899254/v1/f0a0f58814cb747a6365e9c7.jpeg"},{"id":86759230,"identity":"297f0400-e2f3-4264-aa46-82b8c91545ce","added_by":"auto","created_at":"2025-07-15 09:57:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1062348,"visible":true,"origin":"","legend":"\u003cp\u003e2a) and 2b) Ultrasound B scan of the left eye with homogenous localised fusiform elevation of choroid and shallow retinal detachment at the posterior pole correlating with the colour fundus picture.\u003c/p\u003e\n\u003cp\u003e2c) FAF of right eye hypoautofluorescent disc and macula\u003c/p\u003e\n\u003cp\u003e2d) and 2e) Autofluorescence image of left eye depicting hyper autofluorescence in the areas of fluid accumulation and speckled autofluorescence over macular area.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6899254/v1/08eacfe824b5ba9ede62f032.png"},{"id":86759234,"identity":"3bb9a5a4-f781-4676-a387-bb1c546d63ad","added_by":"auto","created_at":"2025-07-15 09:57:38","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":228722,"visible":true,"origin":"","legend":"\u003cp\u003eLeft eye Fundus Fluoresceine Angiogram showing hypofluorescence due to blockage by retinal haemorrhages and non-perfusion due branch retinal artery occlusion, with disc leak. Late phase showing pin point leaks were noted.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6899254/v1/7ffceed0a54d6a49a6d4db95.jpeg"},{"id":86758185,"identity":"a05599d9-e0cf-4e12-b796-62071f7d25db","added_by":"auto","created_at":"2025-07-15 09:49:38","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":234765,"visible":true,"origin":"","legend":"\u003cp\u003e4) and 5) Serial color fundus photographs and OCT B scan of the patient throughout the entire course of treatment.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6899254/v1/0410a0f90ff15e2ff56a73d8.jpeg"},{"id":86759540,"identity":"13265fcb-fa3c-4e4f-b3d6-aafe81340526","added_by":"auto","created_at":"2025-07-15 10:05:38","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":272948,"visible":true,"origin":"","legend":"\u003cp\u003e4) and 5) Serial color fundus photographs and OCT B scan of the patient throughout the entire course of treatment.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6899254/v1/d6c8549b95274ba74acd04f0.jpeg"},{"id":86759231,"identity":"5485ba3d-2d7d-4dc3-a9b6-5e9e30f0193d","added_by":"auto","created_at":"2025-07-15 09:57:38","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1120323,"visible":true,"origin":"","legend":"\u003cp\u003eResolution of disease depicted using multi-modal imaging\u003c/p\u003e","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6899254/v1/45ccbf56e6cb04deba7c3c99.jpeg"},{"id":86759543,"identity":"41f4d8f3-bf5c-4449-9b54-81e969397206","added_by":"auto","created_at":"2025-07-15 10:05:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3401132,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6899254/v1/5794f9e1-0d26-4f2a-927b-51a6b5f0d74f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"There’s more than meets the eye: Posterior pole conundrum","fulltext":[{"header":"Summary","content":"\u003cp\u003ePosterior scleritis can involve optic nerve and retinal vessels causing optic neuritis and retinal artery occlusion further affecting the visual prognosis. A clinician should have a high index of suspicion for diagnosing posterior scleritis which can be a great mimicker. Timely management can save vision in such patients.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eInflammatory conditions may cause vascular complications in the form of retinal haemorrhages, retinal vascular hyperpermeability, retinal vascular occlusion, macroaneurysms, retinal or choroidal neovascularization, and retinochoroidal anastomosis\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Though involvement of artery is rare, but few cases have been reported. We report a case of optic neuritis with branch retinal artery occlusion secondary to posterior scleritis.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 41-year-old male presented with chief complaints of sudden diminution of vision after waking up in morning in left eye for past one month with painful ocular movements with a systemic history of a recent diagnosis of hypertension but not on any anti-hypertensive medications. Patient does not give any history of similar episode in the past or in any other family member. There is no history of trauma, involvement of skin, or joint pain correlating with any systemic involvement. On ophthalmic examination, the best corrected visual acuity (BCVA) was 20/20 in right eye and counting fingers at 1 metre in left eye. Intraocular pressure (IOP) in both eyes was normal, anterior segment examination was unremarkable except afferent pupillary defect in the left eye. Fundus examination was normal in the right eye and the left eye revealed a clear media with optic disc edema, multiple superficial retinal haemorrhages in temporal peripapillary region with an area of retinal whitening over macula infero-temporally with a large pocket of sub-retinal fluid (SRF) just superior to macula (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Patient was subjected to a battery of ocular investigations. Optical Coherence tomography (OCT) was normal in right eye; however, the left eye revealed an elevated foveal contour with hyperreflectivity of inner retinal layers, a neurosensory detachment superior to macula involving fovea, intra-retinal hypo-reflective cystic spaces in inner retinal layers and an underlying choroidal mound (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ee). Ultrasonography of the left eye showed a shallow elevation at the optic nerve head (ONH) with a hyper-echoic membranous echo arising from ONH and extending inferiorly till posterior pole with grossly increased retino-choroidal complex thickness and with sub-tenon’s fluid (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). Fundus auto-fluorescence (FAF) revealed hyper autofluorescence in the areas of fluid accumulation and speckled autofluorescence over the macular area (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). On evaluation, patient’s blood pressure was raised to 138/102 mmHg. After systemic investigations which were normal except slightly elevated serum homocysteine levels, both eyes fundus fluorescein angiography was done which revealed grossly delayed arterio-venous transit phase along with a blocked fluorescence in the region of infero-temporal macular branch retinal artery in left eye, along with blocked fluorescence around the disc corresponding to the disc edema. Late phase angiography depicted disc leakage, along with pooling of dye in serous retinal detachment involving macula and just superior to macula with multiple pin point leakages temporal to disc (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Provisional diagnosis of optic neuritis with branch retinal artery occlusion (BRAO) secondary to posterior scleritis was made. After physician review and ruling out all infectious causes, oral steroids (1mg/kg/day in tapering dose) were started. On subsequent visits, patient was symptomatically better with a marked reduction in ocular pain as well as a subjective and objective improvement in vision. On serial fundus examination, there was resolving disc edema, disc haemorrhages, reduction in retinal edema and whitening secondary to BRAO and a resolving pocket of SRF (Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOn his last visit after 5 months, his BCVA was 20/20 in the right eye and improved to 20/80 in the left eye. IOP was normal in both eyes. Fundus examination of the left eye revealed a clear media, mild disc pallor with foveal thinning with resolved disc haemorrhages, resolved retinal whitening secondary to BRAO and SRF clinically as well as on OCT (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eScleritis is primarily immune-mediated vasculitis due to antigen-specific T-cell activation and immune complex deposition. Posterior scleral inflammation can involve optic nerve and retinal vessels, resulting in vascular occlusions\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Cilioretinal artery occlusion, retinochoroidal infarction, and combined retinal vascular occlusion have been reported\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Several mechanisms have been described in literature which led to the development of BRAO secondary to posterior uveitis. BRAO happens at the site of an active focus of retinitis or retinochoroiditis. It could be due to a direct compression by foci of retinitis or chorioretinitis causing interruption of the blood flow. Arterial occlusion may also occur due to arteriolar contraction resulting from increased blood viscosity and inhibition of coagulation due to heparin release from the mast cells in response to an acute inflammatory stimulus\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Another mechanism could be perivasculitis from the infiltration of the vessel wall by the inflammatory cells, which may lead its thickening and hence, disruption of blood flow and arterial thrombosis\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eBrown et al\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e has reported an 81% prevalence of rubeosis iridis (mean time was 11.8 weeks) and neovascular glaucoma in patients with BRAO secondary to posterior scleritis. At the last follow-up at 5 months, our patient did not have any such complication as mentioned above. Multimodal imaging is the key to diagnosis in such cases with atypical presentations. In addition, a strong index of clinical suspicion is needed for clinching the diagnosis and the right management of such patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEarly and appropriate treatment with oral steroids in inflammatory conditions may help induce prompt resolution of the ocular inflammation and reperfusion of the occluded artery and improve visual outcome as seen in our case.\u003c/p\u003e"},{"header":"Limitation","content":"\u003cp\u003eDue to rarity of this ophthalmic condition, more cases need to be studied in detail to review varied atypical presentation and complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003col\u003e\n \u003cli\u003eEthics approval and consent to participate: Taken\u003c/li\u003e\n \u003cli\u003eConsent for publication: Taken\u003c/li\u003e\n \u003cli\u003eAvailability of data and materials: Not Applicable\u003c/li\u003e\n \u003cli\u003eCompeting interests: No interest\u003c/li\u003e\n \u003cli\u003eFunding: Not Applicable\u003c/li\u003e\n \u003cli\u003eAcknowledgements: Not Applicable\u003c/li\u003e\n \u003cli\u003eConsent from Parents: Signed informed consent obtained for publishing the data\u003c/li\u003e\n \u003cli\u003eAuthors\u0026apos; contributions: Dr Isha Agarwal.: report writing, Data collection, report editing. Dr Anju Bansal : Case report writing, Data Collection\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBr\u0026eacute;zin AP (2012) Uveitis. Presse Med 41:10\u0026ndash;20\u003c/li\u003e\n \u003cli\u003eYamanaka E, Ohguro N, Kubota A et al (2004) Features of retinal arterial macroaneurysms in patients with uveitis. Br J Ophthalmol 88:884\u0026ndash;886\u003c/li\u003e\n \u003cli\u003eWilhelmus KR, Grierson I, Watson PG. Histopathologic and clinical associations of scleritis and glaucoma. Am J Ophthalmol 1981; 91: 697\u0026ndash;705.\u003c/li\u003e\n \u003cli\u003eShukla D, Chandramohan K, Rao N et al. Posterior scleritis causing combined central retinal artery and vein occlusion. Retina 2004; 24: 467\u0026ndash;469.\u003c/li\u003e\n \u003cli\u003eSahu DK, Rawoof AB. Cilioretinal artery occlusion in posterior scleritis. Retina 2000; 20: 303\u0026ndash;305.\u003c/li\u003e\n \u003cli\u003eFrost AN, Sparrow JM, Rosenthal AR. Posterior scleritis with retinal vasculitis and choroidal and retinal infarction. Br J Ophthalmol 1994; 78: 410\u0026ndash;412.\u003c/li\u003e\n \u003cli\u003eBraunstein RA, Gass JDM (1980) Branch artery obstruction caused by toxoplasmosis. Arch Ophthalmol 98:512\u0026ndash;513\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOrmerod LD, Skolnick KA, Menosky MM et al (1998) Retinal and choroidal manifestations of cat-scratch disease. Ophthalmology 105:1024\u0026ndash;1031\u003c/li\u003e\n \u003cli\u003eBrown GC, Duker JS, Lehman R, et al. Combined central retinal artery\u0026ndash;central vein obstruction. Int Ophthalmol 1993;17:9\u0026ndash;17.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"BRAO, Oral Steroids, Posterior scleritis, SRF, Sub-tenon fluid","lastPublishedDoi":"10.21203/rs.3.rs-6899254/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6899254/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTo report the clinical features and management using multimodal imaging of optic neuritis and branch retinal artery occlusion (BRAO) associated with posterior scleritis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA 41-year-old male, recently diagnosed with hypertension, presented with sudden onset diminution of vision with painful eye movements. Patient underwent complete ophthalmic evaluation with systemic evaluation\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eEarly diagnosis led to improvement in BCVA at presentation from counting fingers at 1 metre to 20/80 at 5 month follow up with resolution of subretinal fluid clinically.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eEarly and prompt diagnosis can prevent from irreversible vision loss due to optic neuritis and BRAO secondary to posterior scleritis.\u003c/p\u003e","manuscriptTitle":"There’s more than meets the eye: Posterior pole conundrum","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 09:49:34","doi":"10.21203/rs.3.rs-6899254/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-21T06:12:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-19T17:01:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-18T22:27:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"41815166742873222099343129242072769482","date":"2025-07-14T09:03:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47889172439074995780938914121129541871","date":"2025-07-13T06:11:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175090067935806124542849021217381371887","date":"2025-07-12T14:38:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310441736304558346008210740205166137693","date":"2025-07-12T11:30:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64121879982688298068044819256121912686","date":"2025-07-10T07:06:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-09T22:42:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-09T22:27:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-08T06:20:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-07T16:47:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2025-07-07T16:45:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9b5f8181-ba32-4ef9-83e4-bf49d165dde9","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T09:53:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 09:49:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6899254","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6899254","identity":"rs-6899254","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}