1903 Open Access J Pak Med Assoc Abstract A case of nodular posterior scleritis in a 25-year-old male who presented with a 14-day history of unilateral decline in vision, pain, and redness in his right eye. Slit lamp examination of the right eye revealed dilated episcleral vessels present nasally as well as a choroidal mass at the nasal periphery of the fundus, associated with choroidal oedema. Systemic evaluation and imaging of the choroidal mass were performed to rule out choroidal tuberculoma and choroidal metastasis. Ultrasound B-scan of the right eye showed marked thickening of the nasal sclera resulting in sympathetic choroidal oedema without the characteristic T-sign. Nodular posterior scleritis with associated choroiditis, was diagnosed without any underlying systemic illness. The patient was immediately started on systemic steroids and later on subcutaneous Methotrexate as advised by the rheumatologist, to which he responded well and his vision signifcantly improved from 6/60 to 6/9, gradually during his treatment course. Keywords: Posterior scleritis, Choroiditis, Choroidal mass, Methotrexate. DOI: https://doi.org/10.47391/JPMA.7895 Submission completion date: 09-10-2022 Acceptance date: 29-04-2023 Introduction Posterior scleritis, a relatively unique and under-recognised type of scleral infammation, commonly reported in middle-aged females, accounts for 2%-12% of all forms of scleritis. 1,2 It can be idiopathic, related to some autoimmune condition or infection like Wegener Granulomatosis, rheumatoid arthritis and tuberculosis. Misdiagnosis of intraocular infammation, ocular tumours, and orbital infammation can be made due to its variable presentation. Both posterior scleritis and orbital infammatory syndrome present with similar orbital signs and respond well to steroids thus making it difficult to distinguish between them. 3,4 We report an unusual presentation of nodular posterior scleritis and choroiditis in a young man, who was initially diagnosed and investigated as a choroidal mass. Case Report n October 2020, a 25-year-old male presented to the Ophthalmology Department of Shifa International Hospital, Islamabad, with complaints of blurry and distorted vision in his right eye, along with discomfort, mild pain, and redness persisting for 15 days. He gave no history of either sore throat or contact with a patient with tuberculosis. His past surgical and medical history was unremarkable and he was using topical Tobramycin and artifcial tears. His general physical examination was normal. Unaided visual acuity was 6/60 in the right eye and 6/6 in the left eye according to Snellen’s chart. With pinhole, right eye’s vision improved to 6/12 corresponding to -3.50 DS refractive error according to autorefraction. On slit-lamp examination, the right eye’s anterior segment showed dilated episcleral vessels present nasally with mild conjunctival hyperaemia, +1 cells in the anterior chamber, and was phakic. Dilated fundus exam showed clear posterior vitreous, localised choroidal elevation present nasally extending from 1 o’clock to 5 o’clock with mild optic disc swelling, and few choroidal folds temporal to the disc involving the macula. (Figure-1). The left eye’s examination was normal. Intraocular pressures were 14mm Hg and 15mm Hg in the right and left eyes, respectively. 1,2 Department of Ophthalmology, Shifa International Hospital, Islamabad, Pakistan; 3 Fourth Year MBBS Student, Allama Iqbal Medical College, Lahore, Pakistan; 4 Department of Ophthalmology, Suhail Oculab Hospital, Lahore, Pakistan; 5 Department of Rheumatology, Shifa International Hospital, Islamabad, Pakistan. Correspondence: Muhammad Amer Awan. Email: dramer_awan@yahoo.co.uk ORCID ID. 0000-0002-0043-1930 CASE REPORT Nodular posterior scleritis with associated choroiditis masquerading as a choroidal tumour: A Case Report Muhammad Amer Awan 1 , Fatima Mohsin 2 , Abdullah Ahmed 3 , Muhammad Suhail Sarwar 4 , Tahir Hashmi 5 Figure-1: Colour fundus montage photograph of the right eye illustrating choroidal elevation present nasally vs normal colour fundus photograph of the left eye.