Seasonal Hyperacute Panuveitis from the highest reported altitude: co-occurrence with scleritis - an unusual presentation.

Purpose: Seasonal Hyperacute Panuveitis (SHAPU) is a severe, rapid-onset panuveitis primarily affecting children, often linked to the setae released in the air or by contact with female moths of the genus Gazalina (Lepidoptera, Notodontidae), or with their egg masses laid on various substrates. This study aims to report a rare case of SHAPU from the higher altitude of Nepal with an alpine climate, with concurrence of necrotising scleritis. To the best of our knowledge, this is the first report of SHAPU at high elevation.

Case report: A 27-year-trekker male from an alpine climatic region of eastern Nepal was referred to our department, tertiary eye care in Nepal, with a history of sudden onset of redness, pain and decreased vision in his left eye following an indirect contact with a female Gazalina moth resting in his trekking bag during an ascent from 2,364 to 4,371 m above sea level. Circumcorneal congestion and cells, and flare were observed on clinical examination in the anterior chamber. A necrotising patch was present at the anterior sclera. The details of the lens, vitreous and retina were obscured because of hazy media. Ocular ultrasonography showed hyperechoic shadows in the vitreous with a thickening retina-choroid-sclera complex, suggestive of vitritis. He underwent treatment with antibiotics and steroids via all possible routes (topical, intraocular, periocular and systemic), and the scleral perforation could be prevented, but the visual rehabilitation was not possible.

Conclusion: SHAPU primarily affects the uveal tissue, but its spread of uveal inflammation to the scleral tissue must be borne in mind. This SHAPU case from a high altitude with intense ocular pain suggests new aspects of SHAPU's pathophysiology, contrasting with its typical painless presentation, warranting further research on the study moth's habitat at higher altitudes.