A 30-year-old Caucasian male, with no significant medical history, was referred to our department for a melanoma of the choroid in the left eye (LO) in November 2005.
Since August 2005, the patient had noticed a unilateral decrease in visual acuity (VA) in the LA. For the past month he had been complaining of eye pain in the left eye.
The VA of the right eye (OD) was 10/10 with a spherical correction of -0.5 D, that of the OI was <1/10 without correction and 8/10 with an added spherical correction of -5 D.
The ophthalmological examination of the OD showed no peculiarities.
The slit-lamp examination of the OI showed marked ciliary injection, a mild inflammatory reaction in the anterior chamber and a bulging iris; the ocular pressure (OT) was 17 mmHg. A circumscribed amelanotic mass was prominent in the nasal sector of the fundus. Ultrasound B showed thickening of the ocular wall exceeding 5 mm. A hypoechogenic area was observed in the extra-scleral space. On fluorescein and indocyanine green angiography this lesion was surrounded by well visualised choroidal folds; no intratumoural vascular network of its own was observed.

An orbito-cerebral magnetic resonance imaging (MRI) scan confirmed the contrast-enhancing nodular scleral thickening in the postero-internal region of the RO, without revealing other lesions.

A thorough work-up for rheumatic aetiology (rheumatoid factor, antinuclear antibodies, cANCA, antiphospholipid antibodies) and infectious aetiology (HAART, toxocarosis) was negative. Blood calcium levels were normal: 2,39 mmol/l. Chest X-ray was normal. The slightly increased angiotensin converting enzyme: 73U/L (normal, 10-55) was compatible with a granulomatous condition, but the rest of the examinations did not provide any other arguments in favour of sarcoidosis or tuberculosis.
Based on the anamnesis, clinical, angiographic, ultrasound and MRI findings, the diagnosis of giant posterior scleritis was made. An extra-scleral biopsy was performed and histopathological examination confirmed granulomatous scleritis compatible with sarcoidosis (absence of pathogens visible by Ziehl-Neelsen, Gram, methamine silver and PAS staining).

Oral corticosteroid treatment was started at a dose of 1 mg/kg/day, gradually reducing the dose, due to a good therapeutic response, to 0.5 mg/kg/day after 6 months of treatment. A local guideline of dexamethasone 0.1%, 1 drop 3 times a day, to treat inflammation in the anterior chamber; and atropine 1%, 1 drop 3 times a day, to reduce ciliary spasm, was added to the LAA.
The OI control examination at 6 months showed a VA of 10/10 with a spherical correction of +0.50D. The ciliary injection disappeared as well as the inflammatory reaction in the anterior chamber, the lens was clear; TO was 15 mmHg. In the fundus, the solid elevation in the nasal sector was flattened. On ultrasound B the total thickness of the eye wall in the lower nasal sector was approximately 2 mm.

