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Visual acuity (VA) was 20\/20 in right eye (OD) and counting fingers (CF) at 1 foot in OS. Slit lamp examination revealed 2\u2009+\u2009anterior chamber (AC) cells, optic disc edema (ODE) with elevated appearance of macula in OS. Optical coherence tomography (OCT) showed significant subretinal fluid (SRF) in macula, B-scan ultrasound (US) demonstrated T-sign in OS. Orbital MRI was also consistent with posterior scleritis and periorbital inflammation. Extensive systemic work-up was unremarkable. Thus, the patient was started on intravenous methylprednisolone (IVMP) 30\u00a0mg\/kg\/day for 3 days, along with topical therapy in OS, which led to an improvement of proptosis, EOM restriction, AC cells, as well as ODE and SRF in macula in OS. Fluorescein angiography (FA) showed leakage from optic disc in OS. The patient was then switched to oral prednisone with slow tapering and started on methotrexate (MTX). Given the recurrence of proptosis and painful eyelid swelling on systemic steroid tapering, serum IgG4 levels were ordered and found to be elevated at 149.9\u00a0mg\/dL (range, 1\u201399). Therefore, the patient was diagnosed as \u2018possible\u2019 IgG4-ROD <jats:italic>(based on diagnostic criteria)<\/jats:italic> and started on infliximab (7.5\u00a0mg\/kg) and IVMP monthly infusions with continuation of MTX 20\u00a0mg weekly and slower tapering of oral prednisone, which led to resolution of clinical findings, improvement of VA to 20\/20 in OS.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusion and importance<\/jats:title>\n            <jats:p>Posterior scleritis may be the initial presentation of IgG4-ROD in children. Refractory course is not uncommon. Biologics are effective in the long-term control of inflammation.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1186\/s12348-025-00459-9","type":"journal-article","created":{"date-parts":[[2025,3,27]],"date-time":"2025-03-27T16:59:34Z","timestamp":1743094774000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["IgG4-related ophthalmic disease presenting as posterior scleritis in a pediatric patient"],"prefix":"10.1186","volume":"15","author":[{"given":"Irmak","family":"Karaca","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Albert John","family":"Bromeo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Azadeh","family":"Mobasserian","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amir","family":"Akhavanrezayat","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charles","family":"DeBoer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zheng Xian","family":"Thng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jia-Horung","family":"Hung","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Woong-Sun","family":"Yoo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anadi","family":"Khatri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Negin","family":"Yavari","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ba Trung","family":"Nguyen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dalia","family":"El Feky","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cigdem","family":"Yasar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Osama","family":"Elaraby","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aim-On","family":"Saengsirinavin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaoyan","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frances Andrea","family":"Anover","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ankur Sudhir","family":"Gupta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diana V.","family":"Do","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Or","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Quan Dong","family":"Nguyen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,3,27]]},"reference":[{"issue":"4","key":"459_CR1","doi-asserted-by":"publisher","first-page":"469","DOI":"10.1016\/s0002-9394(00)00710-8","volume":"130","author":"DA Jabs","year":"2000","unstructured":"Jabs DA, Mudun A, Dunn JP, Marsh MJ (2000) Episcleritis and scleritis: clinical features and treatment results. 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