The Red Eye That Did Not Respond: A Diagnostic Challenge in Scleritis

Abstract Scleritis is a severe ocular inflammatory condition that can be either immune-mediated or infectious. Infectious scleritis is relatively uncommon but often mimics immune-mediated disease, leading to delayed diagnosis and inappropriate therapy. We report the case of a 34-year-old female who presented with pain, redness, watering, and discharge in the left eye for 10 days, unresponsive to topical moxifloxacin prescribed for presumed conjunctivitis. Examination revealed localized scleral congestion with a yellowish abscess and overlying conjunctival ulceration. AS-OCT demonstrated scleral oedema, dilated vessels, and separation of collagen fibrils. Laboratory tests and microbiological evaluation were negative for organisms. The patient was treated empirically with fortified cefotaxime and tobramycin eye drops, azithromycin ointment, oral doxycycline, and NSAIDs, resulting in rapid improvement and complete resolution within two weeks. This case emphasizes the need for early clinical suspicion and empirical broad-spectrum antibiotics in suspected infectious scleritis, even with negative cultures, and highlights the role of AS-OCT in diagnosis and monitoring.