The spectrum of postoperative scleral necrosis

Necrotizing Scleritis: A Review

Necrotizing scleritis is the most destructive and vision-threatening form of scleritis. Necrotizing scleritis can occur in systemic autoimmune disorders and systemic vasculitis, as well as following microbial infection. Rheumatoid arthritis and granulomatosis with polyangiitis remain the commonest identifiable systemic diseases associated with necrotising scleritis. Pseudomonas species is the most common organism causing infectious necrotizing scleritis, with surgery the most common risk factor. Necrotizing scleritis has the highest rates of complications and is more prone to secondary glaucoma and cataract than other phenotypes of scleritis. The differentiation between non-infectious and infectious necrotizing scleritis is not always easy but is critical in the management of necrotizing scleritis. Non-infectious necrotizing scleritis requires aggressive treatment with combination immunosuppressive therapy. Infectious scleritis is often recalcitrant and difficult to control, requiring long-term antimicrobial therapy and surgical debridement with drainage and patch grafting due to deep-seated infection and the avascularity of the sclera.

Infectious Scleritis - Clinical Characteristics, Causative Factors, and Treatment Outcomes in an Indian Population

PURPOSE

To study the clinical features, causative factors and treatment outcomes in patients with infectious scleritis seen in India.

METHODS

A retrospective study of all patients examined at a tertiary care center between August 2012 and March 2021.

RESULTS

Forty-five patients (45 eyes; mean age 52.7 ± 17.5 years) were included in the study. The mean duration of symptoms was 3.1 ± 4.4 months. Inciting factors were found in 53.3% (injury: 33.3%; ocular surgery: 20.0%). The scleritis was predominantly anterior (97.8%), with multiple lesions in 40.0%, a solitary lesion in 31.1%, and diffuse in 28.9%. Associated features included uveitis (51.1%), keratitis (37.8%), hypopyon (15.6%), and endophthalmitis (6.7%). Causative organisms included bacteria (53.3%), fungi (35.6%), and presumed herpes virus (11.1%). All patients were treated with antimicrobial agents along with systemic corticosteroids where indicated. Surgical treatment included scleral debridement (37.8%), patch grafts (4.4%), and penetrating keratoplasty (2.2%). Complete resolution of scleritis was seen in 86.7%, with a mean duration of therapy of 2.9 ± 2.5 months. The mean follow-up was 8.3 ± 14.3 months. 51.1% of patients lost functional vision (<6/60). Causes of decreased vision included corneal scar, cataract, macular scar, glaucomatous optic atrophy, and phthisis bulbi. On bivariate analysis, poor visual acuity at presentation was associated with a worse visual outcome (p = 0.02). Other risk factors included necrotizing scleritis, multifocal scleritis, the presence of keratitis and uveitis.

CONCLUSION

In our study, infectious scleritis resulted from bacterial and fungal infections. The scleritis resolved in most subjects, however, vision loss was frequent due to infection-related complications.

Surgically induced necrotizing scleritis (SINS): Is it a standalone condition or a variant of necrotizing scleritis?

PURPOSE

To report the clinical pattern of surgically induced necrotizing scleritis (SINS) in a tertiary eye care center in Southern India.

METHODS

Retrospective analysis of all SINS cases visiting the uveitis clinic of a tertiary eye institute between January 2009 and April 2019.

RESULTS

In total, 15 patients with a median age of 65 (IQR: 52-70) years were included in the study. Male (53%) predominance was noted, and SINS was unilateral (100%) in all cases. Most (87%) of the patients developed SINS after a single surgical procedure, with a median onset period of 251 (IQR: 127-1095) days. None of these patients had any evidence of systemic association. Ocular hypertension (n = 3, 20%), and cataract (n = 5, 33%) were the most common complications. When compared with a cohort of patients with idiopathic necrotizing scleritis, the index study did not find any statistically significant difference between SINS and idiopathic scleritis.

CONCLUSION

SINS is idiopathic necrotizing scleritis rather than an independent entity of scleritis.

Clinical Course and Outcomes of Autoimmune Versus Non-Autoimmune Surgically Induced Scleral Necrosis: A Multicentric Comparative Study

BACKGROUND

To analyze the clinical course and outcomes of autoimmune vs. non-autoimmune surgically induced scleral necrosis (SISN).

METHODS

Multicentric, retrospective, comparative cohort study. Eighty-two eyes of 70 patients with SISN were classified according to pathogenic mechanism into autoimmune vs. non-autoimmune. Main outcome measures included necrosis onset, type of surgery, associated systemic disease, visual acuity, and treatment were analysed in patients followed for ≥ 6 months.

RESULTS

Forty-six (65.7%) patients were women, and the median age was 66 (range: 24-90) years. Most patients (82.9%) had unilateral disease. The median time between surgery and SISN onset was 58 (1-480) months. Thirty-one (37.8%) eyes were classified as autoimmune, and 51 (62.2%) as non-autoimmune SISN. Autoimmune SISN was associated with a shorter time between the surgical procedure and SISN onset than non-autoimmune cases (median of 26 vs. 60 months, p = 0.024). Also, autoimmune SISN was associated with cataract extraction (93.5% vs. 25.5%, p < 0.001), severe scleral inflammation (58.1% vs. 17.6%, p < 0.001), and higher incidence of ocular complications (67.7% vs. 33.3%, p = 0.002) than non-autoimmune cases. Remission was achieved with medical management alone in 44 (86.3%) eyes from the non-autoimmune and in 27 (87.1%) from the autoimmune group (p = 0.916). Surgical management was required in 11 (13.4%) eyes, including two requiring enucleations due to scleral perforation and phthisis bulbi.

CONCLUSIONS

Eyes with autoimmune SISN had a higher rate of cataract surgery, severe scleral inflammation, and ocular complications. Early SISN diagnosis and appropriate management, based on clinical features and pathogenic mechanisms, are critical to avoid sight-threatening complications.

Mimickers of anterior uveitis, scleritis and misdiagnoses- tips and tricks for the cornea specialist

BACKGROUND

Anterior uveitis, inflammation of the anterior chamber and related structures, is a cohort of diseases that can present to almost any general or sub-specialty Ophthalmology practice. Its features classically involve anterior chamber cell and flare. Below the surface of these two signs exist a panoply of diagnoses. BODY: The purpose of this review is to provide a general framework for diagnoses of anterior uveitis that are often missed as well as non-uveitic pathologies that often mimic anterior uveitis. Diagnostic deviation in either direction can have vision-threatening and rarely life-threatening consequences for patients. Using a comprehensive literature review we have collected a broad spectrum of etiologies of anterior uveitis that are easily missed and non-uveitic pathologies that can masquerade as anterior uveitis.

CONCLUSIONS

We present a focused review on specific misdiagnosed anterior uveitis pathologies and some of the conditions that can masquerade as anterior uveitis and scleritis.

Surgically-Induced Necrotizing Scleritis After Pars Plana Vitrectomy: A Case Report

Surgically induced necrotizing scleritis (SINS) is a rare delayed hypersensitivity reaction following ocular surgeries, characterized by pain and redness at the surgical site. While commonly reported in various ocular surgeries, its occurrence after vitreoretinal procedures remains infrequent. We present a case of a 61-year-old diabetic male who developed progressive scleral melting and uveal exposure two months after an uneventful 23-gauge vitrectomy for retinal detachment. The infectious and immunologic profile was negative. Despite aggressive medical and surgical interventions, the patient exhibited advancing scleral melting. The diagnostic challenge lies in determining the relative contributions of trauma, epithelial breakdown, immune activation, and infection in these patients. Our patient's uncontrolled diabetes potentially aggravated vascular disruption, contributing to delayed wound healing and immune complex deposition. The treatment involved topical steroids with broad-spectrum antibiotics, followed by conjunctival flap and oral corticosteroids. This case underscores the importance of early diagnosis, cautious immunosuppression, and thorough infection evaluation in managing postoperative scleritis. The limitations include a single culture test and the patient being lost to follow-up.

Surgical Outcome After Treatment of Radiation-Induced Scleral Necrosis in Patients With Uveal Melanoma

PURPOSE

Surgical repair might be required in patients with uveal melanoma (UM) that develop advanced forms of radiation-induced scleral necrosis (RISN). In this monocentric long-term observational study, we aimed at analyzing the treatment outcome after RISN surgery.

METHODS

All consecutive cases with UM who underwent surgical intervention for RISN between 1999 and 2020 were included. Achievement of the tectonic stability and evaluation of incidence and the risk factors for a repetitive patch surgery (RPS) were the main endpoints.

RESULTS

The final analysis included 57 patients (mean age: 58.7 years; 63.2% female patients), where 55 individuals underwent a patch grafting, and 2 cases were treated with conjunctival reconstructive surgery. The mean follow-up time after grafting was 38.5 months (0.03-221.1 months). Tectonic stability was achieved in 56 (98.3%) patients. Scleral graft (38/55, 69.1%) was the most frequent patching material, followed by Tutopatch (7/55, 12.7%), corneal graft (7/55, 12.7%), dura graft (2/55, 3.6%), and fascia lata (FL) graft (1/55, 1.8%). Eleven patients (20%) underwent RPS after the mean time of 12.9 months (0.3-50.3 months). In the final multivariate Cox regression analysis, the use of Tutopatch (5/7; 71.4%, adjusted hazard ratio = 4.66, P = 0.044) and RISN progression after patch grafting (9/11; 81.8%, adjusted hazard ratio = 9.67, P = 0.008) were independent risk factors for RPS.

CONCLUSIONS

RISN surgery maintains long-term tectonic stability in most of the cases underwent surgical repair for RISN after brachytherapy for UM. Depending on graft material and, particularly, further RISN progression, an RPS might be necessary in certain cases.

Surgically-Induced Necrotizing Scleritis After Scleral Buckling With Stenotrophomonas maltophilia Infection

Surgically induced necrotizing scleritis (SINS) is a rare inflammatory disease of the sclera that occurs following ocular surgery, specifically pterygium surgery and scleral buckling. Here, we report a case of SINS in a 78-year-old female patient after segmental scleral buckling for rhegmatogenous retinal detachment. The retina was restored after scleral buckling, and the postoperative course was uneventful. However, the patient developed ocular discharge and conjunctival hyperemia, indicating infection, after two months. The sclera became thinner and intraocular inflammation developed after buckle removal. Stenotrophomonas maltophilia was isolated from the ocular discharge, and the patient was treated with antibacterial agents susceptible to the bacteria. However, her symptoms persisted, and corrected visual acuity decreased from 20/25 to 20/1000. Oral steroid treatment was initiated because of the suspicion of SINS. Intraocular inflammation gradually subsided, the thin sclera was covered by conjunctival tissue, and the patient's corrected visual acuity improved to 20/32, which stabilized her condition. Infection with Stenotrophomonas maltophilia after scleral buckling is extremely rare, and SINS development in such cases is unprecedented.

Surgically Induced Scleritis Associated With Suture Hypersensitivity Following Strabismus Surgery

A 67-year-old woman with history of mild suture hyper-sensitivity presented with localized scleritis after strabismus surgery. After infection was ruled out, the patient was prescribed topical and systemic non-steroidal anti-inflammatory drugs and systemic steroids, which led to full clinical resolution. [J Pediatr Ophthalmol Strabismus. 2024;61(1):e4-e6.].

Surgical induced necrotizing scleritis following intraocular lens replacement

PURPOSE

To report a surgical-induced necrotizing scleritis, as well as its medical and surgical management.

METHODS

Case-report.

RESULTS

An 88 year-old patient with a three-day severe single-left-eye ocular pain. One-time surgery involving PPV with removal of dislocated intraocular lens and secondary implantation of iris-claw Artisan® lens was performed 6 months earlier. Visual acuity of 20/100. Slit-lamp examination revealed a 5 × 2 mm non-suppurative superior scleral defect. Empirical topical antibiotic treatment with dexamethasone, as well as oral doxycycline was started. Infectious and autoimmune diseases were ruled out. Non-infectious scleritis treatment was conducted with intravenous Methylprednisolone 3 day pulses, followed by weekly tapered Prednisone and intramuscular Methotrexate. However, 1 month after the diagnosis, the defect was worsened; hence, a heterologous scleral patch graft was performed and, days after the intervention, Adalimumab was initiated. To date, 6 months later, remains with proper scleral patch, a diary low-dose Prednisone, and spacing Adalimumab treatment.

CONCLUSION

Surgery-induced necrotizing scleritis is a severe condition that compromise the ocular and visual integrity. Proper diagnosis, as well as early treatment is required to achieve remission, prevent relapses, and avoid structural complications. In refractory cases, anti-TNF-α immunotherapy associated with surgical tectonic graft interventions can achieve promising results.

Acute-onset surgically induced necrotizing scleritis after strabismus surgery

Surgically induced necrotizing scleritis (SINS) is an uncommon but devastating complication that may occur days to years after ocular surgery. We report the case of a 32-year-old man who underwent uncomplicated strabismus surgery for large-angle exotropia and developed SINS characterized by painless scleral inflammation, choroidal exposure, and globe ectasia within days of surgery. Work-up revealed no associated infectious process or underlying systemic inflammatory condition. Clinical resolution occurred with oral immunosuppression alone, without need for graft.

Surgically induced scleral necrosis associated with concomitant tuberculosis infection: a diagnostic challenge

Objective

Surgically induced scleral necrosis (SISN) is a potentially blinding sequela that may occur after any ocular procedure. SISN in the context of active tuberculosis is seldom seen. We report a case of a patient with asymptomatic tuberculosis who developed SISN after pterygium surgery.

Methods

A 76-year-old Mexican-mestizo woman from Veracruz, Mexico, was referred to our clinic because of severe disabling pain and scleral thinning in her right eye.

Results

Tubercular-related SISN was finally diagnosed and managed successfully with antitubercular therapy, topical and systemic corticosteroids.

Conclusion

Tuberculosis must be considered as a differential diagnosis of high-risk patients in the context of refractory SISN in endemic countries.

Pediatric Scleritis: An Update

Posterior idiopathic scleritis is the most common type of scleritis observed in childhood. Nevertheless, anterior and even necrotizing inflammatory scleritis may occur as well. Although less frequently than in the adult population, scleral inflammation can be associated with systemic disorders, which should be promptly recognized and treated to avoid both ocular and systemic complications. Hence, a multidisciplinary diagnostic work-up should be performed to rule out primarily infectious and autoimmune causes, such as viral and bacterial infections, anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis, pediatric sarcoidosis, Behçet's disease and HLA-B27-associated diseases. Treatment of scleritis should aim to control ocular inflammation, relieve symptoms and prevent relapses, to avoid complications, preserve visual acuity and improve the child's quality of life. It should be tailored to the patient, considering the type and severity of scleritis, the possible identification of an infectious cause or the presence of an associated rheumatologic condition.

Management of scleral melt

Scleral melting, while rare, can lead to significant ocular morbidity. Several possible risk factors for scleral melt have been identified, such as infection, autoimmune disease, trauma, and post-surgical state, and these may act in combination with each other. Treatment should be tailored according to the etiology and severity of the scleral melt. Medical management may be indicated, especially in cases of autoimmune-related melt; however, surgical procedures are often necessary due to compromised ocular integrity and limited penetration of medications into the avascular sclera. An understanding of the surgical options available and their operative outcomes is particularly important when choosing the appropriate treatment protocol for each patient.

Scleral melt and uveal prolapse following 23-gauge pars plana vitrectomy

Purpose

To report a case of uncontrolled juvenile open angle glaucoma (JOAG), with secondary high axial myopia who presented with scleral melting and uveal prolapse post pars plana-vitrectomy.

Observations

A 17-year-old male juvenile glaucoma patient, not known to have any systemic disease underwent a right eye 23-gauge-pars plana vitrectomy for retinal detachment repair. Three weeks following his surgery he presented complaining of tearing and photophobia in the operated eye in the absence of any ocular pain. Clinical exam revealed enlarged sclerotomy sites with localized conjunctival and episcleral injection, scleral thinning and uveal prolapse. Infectious and serologic work up were obtained to rule out an infectious etiology or underlying autoimmune disease. Patient was successfully managed with topical steroids and a donor scleral patch graft.

Conclusion and importance

This report addresses multiple risk factors for a devastating complication that may occur in predisposed patients, with primary or secondary axial myopia and a compromised sclera. This group of patients can be at risk of post-operative scleral melting and thinning and should be identified pre-operatively and monitored closely during their post-operative course.

Surgically induced diffuse scleritis associated with choroidal detachment following phacoemulsification surgery

PURPOSE

We present a case of a hemorrhagic choroidal detachment associated with a surgical induced diffuse scleritis (SIDS) following phacoemulsification surgery.

CASE REPORT

A-49-year-old healthy male with history of high myopia and pars-plana vitrectomy associated with 360° encircling buckle surgery years ago, who underwent phacoemulsification surgery with in-the-bag intraocular lens implantation on the right eye and developed an important 360° hemorrhagic choroidal detachment on the first-day post-surgery, 10 days later, presented SIDS. First day after surgery, best-corrected visual acuity was hands movement in the affected eye. Ten days later, the patient presented with severe ocular pain and redness on the right eye, the right sclera showed active diffuse inflammation without thinning. A normal collagen vascular profile was found and systemic vasculitic disorders were discarded. The patient responded well to systemic therapy (oral prednisone, 0.5 mg/kg/day at the beginning and then 1 mg/kg/day when scleritis appeared) and 8 weeks later, fundus examination revealed complete resolution of the hemorrhagic choroidal detachment and inflammation.

CONCLUSION

A rare presentation of a surgical induced diffuse scleritis associated with choroidal detachment as an acute complication due to phacoemulsification cataract surgery was presented. Early recognition and treatment led to visual improvement and resolution of the scleritis and choroidal detachment.

Topical Erythropoietin for Treatment of Scleral Necrosis

PURPOSE

To investigate the safety and efficacy of topical erythropoietin for the treatment of scleral necrosis.

METHODS

This study enrolled eight consecutive patients with scleral necrosis due to previous ocular surgery, rheumatoid arthritis-associated necrotizing anterior scleritis, and thermal and chemical burns. Conventional treatments failed to heal avascular scleral lesions in all eyes. Patients were treated with topical erythropoietin (3000 IU/mL) four times a day.

RESULTS

The mean patient age was 37.6 ± 15.5 years. The interval between the development of scleral necrosis and initiation of topical erythropoietin was 25.6 ± 12.0 days. The necrotic sclera completely healed within 31.9 ± 16.9 days in all patients. The avascular lesions did not recur, and there was no evidence of side effects during the study.

CONCLUSION

Our results showed that topical erythropoietin could be safely used to manage scleral necrosis. Randomized clinical trials are needed to further explore the efficacy of this intervention in patients with avascular scleral lesions.

Associations between Sjögren Syndrome, Sociodemographic Factors, Comorbid Conditions, and Scleritis in a Taiwanese Population-Based Study

This nationwide, population-based, retrospective, matched case–control study included 111,960 newly diagnosed patients with scleritis who were identified by the International Classification of Diseases, Ninth Revision, Clinical Modification code 379.0, selected from the Taiwan National Health Insurance Research Database. Demographic characteristics, Sjögren syndrome, and comorbid conditions within 1 year before the scleritis diagnosis were examined using univariate logistic regression analyses, and a paired t-test was used for continuous variables. Adjusted logistic regression was used to compare the prognosis odds ratio (OR) of the patients with scleritis with the controls. After adjustment for confounders, patients with Sjögren syndrome were remarkably more likely to have scleritis than the controls (OR = 33.53, 95% confidence interval (CI) = 27.43–40.97, p < 0.001). Other conditions found to have increased odds of scleritis included post ocular pterygium, glaucoma, and scleral surgery (OR  =  4.01, 95% CI  =  3.64–4.43; OR  =  3.16, 95% CI  =  2.24–4.47; OR  =  6.83, 95% CI  =  5.34–8.74, respectively); systemic infections, such as syphilis, tuberculosis, and a human herpes viral infection (OR  =  4.01, 95% CI  =  2.93–5.50; OR  =  2.24, 95% CI  =  1.94–2.58; OR  =  8.54, 95% CI  =  8.07–9.03, respectively); and systemic diseases, such as rheumatoid arthritis, granulomatous vasculitis, systemic lupus erythematosus, ankylosing spondylitis, and gout (OR  =  2.93, 95% CI  =  2.66–3.23; OR  =  7.37, 95% CI  =  3.91–13.88; OR  =  3.18, 95% CI  =  2.63–3.85; OR  =  5.57, 95% CI  =  4.99–6.22; OR  =  2.84, 95% CI  =  2.72–2.96, respectively). The results strongly support an association between Sjögren syndrome, post ocular surgery, systemic infection disease, systemic autoimmune disease, and scleritis.

Scleritis Following Pterygium Excision: Infection, Autoimmunity, or Both?

The term scleritis refers to a heterogeneous group of disorders characterized by a chronic inflammatory response centered on the sclera and often involving adjacent structures such as the episclera, cornea, and uvea. It is an uncommon but severe, painful, and potentially blinding ocular disease and may occasionally result in perforation of the globe. Through a case report of severe scleritis that occurred after pterygium surgery, the authors expose diagnostic difficulties and emphasize the need for a meticulous diagnostic approach in such a condition.

Infectious Scleritis: Pathophysiology, Diagnosis, and Management

ABSTRACT

Infectious scleritis (IS) is a rare and severe ocular disorder responsible for approximately 5%-15% of all scleritis cases. It is often associated with a poor prognosis due to its similar clinical presentation to autoimmune scleritis, resulting in a delayed diagnosis and treatment. Therefore, differentiating between infectious and noninfectious entities is critical. Several details extracted from the patient's history and clinical examination can raise suspicion for infection. The most common predisposing factor is previous ocular surgery, especially pterygium, cataract, and vitreoretinal surgeries. Ocular trauma, poor contact lens hygiene, "eye-whitening" procedures, and subtenon triamcinolone injections have also been implicated. Clinical features of infection include the presence of scleral necrosis, hypopyon, unifocal or multifocal scleral abscesses, and mucopurulent discharge. Thorough diagnostic testing is essential before excluding infection as a possibility. Empiric broad-spectrum topical and systemic antibiotic therapy should be initiated while awaiting laboratory results and adjusted accordingly. Most IS cases require both aggressive medical and surgical treatment, and various studies have reported favorable outcomes with this combination. At this time, there is no consensus on the management of this severe ocular condition, and future studies are needed to establish clear treatment guidelines.

Hypopyon: Is-it Infective or Noninfective?

Hypopyon usually corresponds to the sedimentation of white blood cells, and it signifies severe intraocular inflammation. This key clinical sign may occur in association with a wide variety of infectious, inflammatory, and neoplastic conditions that may be sight- and, occasionally, life-threatening. A careful history and thorough clinical examination are the cornerstones for orienting the differential diagnosis, identifying the causative agent, and initiating prompt and appropriate treatment. This review outlines the clinical characteristics and management of hypopyon in relation with the underlying causative infectious or noninfectious ocular or systemic diseases.

Use of erythropoietin in ophthalmology: a review

Erythropoietin (EPO) is a glycoprotein hormone that regulates hematopoiesis in the human body. The presence of EPO and its receptors in different tissues indicates that this hormone has extramedullary effects in other tissues, including the eye. We focus on the biological roles of this hormone in the development and normal physiologic functions of the eye. Furthermore, we explore the role of EPO in the management of different ocular diseases - including diabetic retinopathy, retinopathy of prematurity, inherited retinal degeneration, branch and central retinal vein occlusion, retinal detachment, traumatic optic neuropathy, optic neuritis, methanol optic neuropathy, nonarteritic anterior ischemic optic neuropathy, glaucoma, and scleral necrosis.

Infectious necrotizing scleritis and proliferative vitreoretinopathy after scleral buckling in a patient with atopic dermatitis

Purpose

To report a case of necrotizing scleritis and proliferative vitreoretinopathy due to an acute infection following scleral buckling for the management of rhegmatogenous retinal detachment in a patient with untreated atopic dermatitis.

Observations

A 40-year-old man with untreated atopic dermatitis presented with rhegmatogenous retinal detachment in his right eye. He underwent uncomplicated scleral buckling surgery with an encircling silicon sponge band, then noticed severe hyperemia and purulent discharge in the eye at 3 weeks after surgery. The silicon sponge was exposed and had migrated anteriorly. The patient was then diagnosed with post-scleral-buckling infection and underwent scleral buckle removal. Marked scleral thinning due to necrotizing scleritis was evident beneath the scleral buckle. Eye discharge culture findings were positive for Staphylococcus aureus. After removal of the scleral buckle, the patient's necrotizing scleritis improved, but he developed proliferative vitreoretinopathy. The patient then underwent pars plana vitrectomy, which resulted in reattachment of his retina.

Conclusions and Importance

Although postoperative infection within 1 month after scleral buckling is rare, surgeons should note that patients with atopic dermatitis are at high risk of postoperative infection after scleral buckling, leading to the development of sight-threatening complications such as necrotizing scleritis, which could lead to incomplete retinal attachment and proliferative vitreoretinopathy.

Atypical Noninfectious Surgically Induced Necrotizing Scleritis in a Child

Surgically induced necrotizing scleritis (SINS) is recognized as a rare and vision-threatening complication of ocular surgery. In adults, it has been mostly described after multiple ocular surgical procedures such as pterygium excision, glaucoma, and retinal detachment in the same eye. SINS is relatively less likely with single ocular surgery. It has been postulated that multiple surgeries may result in exposure of an antigen that leads to hypersensitivity reaction. Interestingly, it has also been reported after single strabismus surgery in adults. We present a case of unilateral surgically induced scleral necrosis resulting in complete loss of left inferior rectus muscle and muscle sheath in a child 2 weeks after uneventful bilateral strabismus surgery for hypertropia.

The clinical and pathogenic spectrum of surgically-induced scleral necrosis: A review

The onset of scleral necrosis after ocular surgery may have catastrophic ocular and systemic consequences. The two most frequent surgeries causing surgically-induced scleral necrosis (SISN) are pterygium excision and cataract extraction. Several pathogenic mechanisms are involved in surgically induced scleral necrosis. All of them are poorly understood. Ocular trauma increasing lytic action of collagenases with subsequent collagen degradation, vascular disruption leading to local ischemia, and immune complex deposition activating the complement system represents some of the events that lead to scleral necrosis. The complex cascade of events involving different pathogenic mechanisms and the patient's abnormal immune response frequently leads to delayed wound healing that predisposes the development of scleral necrosis. The management of SISN ranges from short-term systemic anti-inflammatory drugs to aggressive immunosuppressive therapy and surgical repair. Therefore, before performing any ocular surgery involving the sclera, a thorough ophthalmic and systemic evaluation must be done to identify high-risk patients that may develop SISN.

Topical Erythropoietin as a Novel Treatment for Necrotizing Scleritis After Pterygium Surgery: A Pilot Study

PURPOSE

To share our initial experience with the innovative use of topical erythropoietin for the treatment of necrotizing scleritis manifesting immediately after pterygium excision surgery.

METHODS

This study enrolled 3 patients who developed necrotizing scleritis immediately after undergoing pterygium excision. All cases with pterygium were primary, and topical mitomycin C and conjunctival autografts were used at the time of surgery. Noninvasive therapy that included ophthalmic lubricants and topical and systemic corticosteroids failed to improve the avascular scleral lesions. The patients were prescribed erythropoietin-containing drops (3000 U/mL) every 6 hours in addition to topical antibiotics and lubricant. The effect of topical erythropoietin on the healing process of avascular scleral lesions was investigated, and its ocular and systemic side effects were evaluated.

RESULTS

The mean age of the participants was 69.0 ± 14.8 years, and 2 of the 3 eyes belonged to male subjects. The time between pterygium surgery and presentation to our clinic was 33.0 ± 14.7 days. There were no infectious causes or underlying systemic diseases in any of the cases. After treatment with topical erythropoietin for an average of 34.3 ± 20.3 days, the lesions were completely vascularized in all 3 eyes without any ocular or systemic adverse effects. The patients were followed up for an average of 126 ± 94 days after discontinuation of erythropoietin. There was no evidence of recurrence during the last examination in any of the eyes.

CONCLUSIONS

Topical erythropoietin might be a safe and an effective method for treating cases of necrotizing scleritis that manifests immediately after pterygium surgery.

Necrotizing scleritis after strabismus surgery in Treacher Collins syndrome

Objective: To describe a case of surgically induced scleral necrosis in Treacher Collins syndrome after strabismus surgery. Methods: A 19-year-old girl underwent bilateral squint surgery. Two weeks postoperatively, she presented with subconjunctival abscess in the left eye. The surrounding conjunctiva was markedly inflamed with raised edges. Surgical debridement, microbiological evaluation and medical management were started immediately. Screening for autoimmune and vasculitic conditions did not provide any positive results. Results: On subsequent follow-up, conjunctival retraction and an area of scleral necrosis with thinning was noted. Significant healing with antibiotics and steroids was noted within one week. The integrity of the globe was well maintained and no further procedure for tectonic support was performed. Conclusion: Surgically induced scleral necrosis can be immune-mediated or following surgical site infection. Pre-existing scleral thinning due to neuroectodermal apoptosis in Treacher Collins syndrome remains a possible explanation for the accelerated necrotising scleritis in our case.

Aspergillus Flavus Necrotising Scleritis following Pars Plana Vitrectomy

PURPOSE

To report a case of fungal necrotising scleritis following pars plana vitrectomy. Results: A 65-year-old lady underwent phacoemlsificication with posterior capsular rupture and posteriorly dislocated lens in her left eye. On the same day she underwent 20 gauge pars plana vitrectomy and phacofragmentation. Postoperative period was uneventful for up to 6 weeks when she developed necrotising anterior scleritis with suppurative nodules. Scraping from the suppuration confirmed the presence of Aspergillus flavus. She was treated with topical Voriconazole and oral Itraconazole. Conclusion: We describe the first case of fungal necrotising scleritis without intraocular inflammation following pars plana vitrectomy (PubMed Search). Infection should be kept in the differential diagnosis of post-operative necrotising scleritis even in the absence of risk factors like hypopyon or diabetes. Early recognition improves final outcome. Medical therapy should be continued even after presumed cure to take care of residual fungi and prevent recurrences.

Delayed Onset Scleromalacia and Conjunctival Bleb Formation Following Intraoperative Mitomycin C Application during Conjunctival Melanoma Excision

Purpose: To present a case of delayed onset scleromalacia and conjunctival bleb formation one year after conjunctival melanoma excision with intraoperative use of mitomycin-C (MMC) and double-freeze-thaw technique. Methods: Case report. Results: A 69-year-old woman had a conjunctival melanoma excised by the ‘no touch technique’ with intraoperative application of 0.02% MMC for 3 min on bare sclera, freeze-thaw cryotherapy and amniotic membrane transplant performed elsewhere. Three months later, she presented to us with a red, sore and painful right eye. Examination revealed severe scleritis. She was treated with lubricants and oral steroids for 6 weeks. She settled well with no recurrence of melanoma. At one year, she developed scleromalacia and conjunctival blebs in the inferonasal quadrant of right eye. She remains under closer observation as she is at high risk of perforation. Conclusion: Caution should be exercised with intraoperative use of MMC on bare sclera during excision and cryotherapy of conjunctival melanoma. As published in the literature, when using MMC, it is recommended to use the lowest dose topically in the form of eye drops in the postoperative period for the shortest time to avoid any sight-threatening complications.

Surgically induced necrotizing scleritis after retinal detachment surgery masquerading as scleral abscess

Scleral necrosis is a rare occurrence after many ocular procedures. In the absence of infection or use of surgical adjuncts such as antimetabolites or radiation, the necrosis is presumed to be directly related to surgical trauma and is hence termed surgically induced necrotizing scleritis (SINS). A high index of suspicion is required for an early diagnosis of SINS and its differentiation from infective scleritis is important as the treatment modalities of these two related conditions are different. We report a case of SINS at sclerotomy site following 23-gauge transconjunctival retinal detachment surgery that was initially suspected to be a scleral abscess. Prompt recognition and institution of topical and systemic steroid therapy helped in limiting the extent of scleral damage.

Transplantation of autologous perichondrium with amniotic membrane for progressive scleral necrosis

PURPOSE

Scleral necrosis with severe ischemia is refractory to conventional treatment because of avascular progressive necrosis. We assessed the therapeutic efficacy and safety of autologous perichondrium transplantation in patients with progressive scleral necrosis (PSN) and analyzed the clinical effects.

METHODS

This study was a prospective, interventional, and noncomparative case series. Reconstructive surgery using autologous perichondrium and amniotic membrane (AM) was performed in patients with PSN who showed progressive ischemic scleral melting with impending perforation state and/or broad avascular area larger than 10 mm in diameter. The primary outcome was restoration of scleral integrity with healthy vascularized epithelium over the graft at six months after surgery. The secondary outcome was complication rate associated with autologous perichondrium graft use.

RESULTS

Eighteen eyes of 14 patients underwent reconstructive surgery using autologous perichondrium patch and AM grafts. Observations indicated the graft provided the eyeball with successful structural integrity in 17 out of the 18 cases (94.4%) at six months after surgery. One eye showed a small scleral defect due to wound dehiscence at four month after the surgery. Additional surgery using perichondrium and AM stabilized the eye. The scleral necrosis healed completely after perichondrium and AM transplantation, even in cases with full-thickness scleral defect. The scleral integrity was maintained until the last follow-up session. There were no serious complications of endophthalmitis or graft infection.

CONCLUSIONS

Reconstructive surgery using autologous perichondrium and AM is an effective method for restoration of scleral integrity and vascularization of the episclera and conjunctiva in eyes with PSN. Therefore, autologous perichondrium can be considered as an appropriate new biologic tissue for PSN.

Histopathological evaluation of scleritis

The sclera is an uncommon site of primary inflammation. Biopsy is infrequently employed in the evaluation of scleritis, but familiarity with its differential diagnosis is instrumental in ensuring efficient histological evaluation. This review provides a clinical overview of scleritis and describes the context in which scleral biopsy might arise. Most cases are associated with systemic autoimmune disease, but a sizeable proportion occur as an isolated disorder. Conditions mimicking autoimmune scleritis include infection and neoplasm. Histological patterns of inflammation in eyes removed surgically or at autopsy have been placed into three groups: (1) autoimmune scleritis characterised by varying mixtures of palisading granulomas, necrosis and vasculitis; (2) infectious scleritis, characterised by acute inflammation and necrosis; and (3) idiopathic scleritis, characterised by chronic non-specific inflammation with follicles and varying amounts of fibrosis. This traditional system of classification may be oversimplified. Aetiological or categorical classification is not always possible on small biopsies given the histopathological overlap of infectious and non-infectious scleritis.

Necrotizing Scleritis After Cosmetic Conjunctivectomy With Mitomycin C

PURPOSE

To report cases of necrotizing scleritis, a sight-threatening complication that can result from cosmetic conjunctivectomy procedures.

DESIGN

Retrospective case series.

METHODS

The medical records of consecutive patients who underwent eye-whitening conjunctivectomy with mitoycin C (MMC) treatment performed by 1 surgeon in South Korea and were referred to the authors' clinic between January 2011 and December 2015 were reviewed. The patients in whom findings of necrotizing scleritis with active inflammation were detected in an avascular area of previous conjunctivectomy were included.

RESULTS

Of a total of 231 patients who had received cosmetic eye whitening, 4 patients who met the inclusion criteria were identified. The average length of time from cosmetic eye surgery to a diagnosis of necrotizing scleritis was 51 months and all patients had unilateral findings of necrotizing scleritis. There was no underlying systemic autoimmunity or infectious etiology in all cases. Three of these 4 patients were treated with a conjunctival flap; however, all 4 received systemic anti-inflammatory treatment with oral corticosteroids. The mean follow-up duration of the patients was 22.75 months.

CONCLUSIONS

Necrotizing scleritis is a severe complication that can arise after cosmetic eye-whitening conjunctivectomy with MMC. Because of the large area of the ocular surface that is treated in eye-whitening with MMC, the necrotizing scleritis that can ensue may be more extensive and severe than the surgically induced necrotizing scleritis following other periocular surgeries such as pterygium removal. Proper anti-inflammatory treatment and surgical intervention should be required for management of this complication.

Tectonic corneal lamellar grafting for surgically-induced necrotizing scleritis after strabismus surgery: Case report & literature review

Purpose

To report the first case of infectious surgically-induced necrotizing scleritis following strabismus surgery which was treated successfully with a tectonic corneal graft.

Observations

We report a case of surgically-induced necrotizing scleritis after strabismus surgery in a 61-year-old gentleman with gout and a subconjunctival abscess. Surgical drainage of the subconjunctival abscess led to a diagnosis of scleral melt which was subsequently treated with a tectonic corneal graft along with aggressive medical management. Over the following eight months, the patient showed no signs of endophthalmitis, graft necrosis, nor graft dehiscence, and serial anterior segment optical coherence tomography imaging demonstrated anatomic stability.

Conclusions and importance

This case offers further insights into a rare but vision-threatening and potentially life-threatening diagnosis. In conjunction with aggressive local and systemic treatment, tectonic lamellar keratoplasty provides good therapeutic and tectonic results for scleral necrosis after strabismus surgery. This case also demonstrates the importance of screening for associated systemic risk factors in any patient with scleritis for appropriate, targeted therapy.

[Scleritis and systemic diseases: What should know the internist?]

Scleritis is an inflammatory disease of the sclera; outer tunic of the eye on which the oculomotor muscles are inserted. It can be associated with a systemic disease up to one time out of 3. These associated diseases are mainly rheumatoid arthritis, vasculitis, including granulomatosis with polyangiitis in the first line and spondyloarthropathies. Before mentioning such an etiology, it is necessary to eliminate an infectious cause, mainly herpetic, which is regularly underestimated. The classification of scleritis is clinical. We distinguish between anterior scleritis and posterior scleritis. Anterior scleritis is diffuse or nodular, usually of good prognosis. Anterior necrotizing scleritis with inflammation is often associated with an autoimmune disease, necrotizing scleritis without inflammation usually reflects advanced rheumatoid arthritis. The treatment of these conditions requires close collaboration between internists and ophthalmologists to decide on the use of corticosteroid therapy with or without immunosuppressors or biotherapies.

Occult Fungal Scleritis

PURPOSE

To heighten awareness of occult fungal scleritis.

METHOD

Case report and review of the literature.

RESULTS

A 73-year-old woman with diabetes mellitus was diagnosed for 3 months with immune-mediated scleritis and subsequently treated with corticosteroids. On referral, the patient had a scleral nodule with contiguous corneal infiltrate and hypopyon. Culture grew Fusarium species not further classified. The infection could not be controlled with antifungal therapy, and the eye was removed. No exogenous or endogenous source for the infection could be identified by clinical history or examination.

CONCLUSION

Fungal scleritis can develop in persons without a history of foreign body injury, minor trauma, or evidence of endogenous fungemia. A high index of suspicion for infectious scleritis must be maintained in persons with presumed immune-mediated scleritis who fail to respond to conventional therapy, particularly if they present with decreased visual acuity.

Curcuma longa Is Able to Induce Apoptotic Cell Death of Pterygium-Derived Human Keratinocytes

Pterygium is a relatively common eye disease that can display an aggressive clinical behaviour. To evaluate the in vitro effects of Curcuma longa on human pterygium-derived keratinocytes, specimens of pterygium from 20 patients undergoing pterygium surgical excision were collected. Pterygium explants were put into culture and derived keratinocytes were treated with an alcoholic extract of 1.3% Curcuma longa in 0.001% Benzalkonium Chloride for 3, 6, and 24 h. Cultured cells were examined for CAM5.2 (anti-cytokeratin antibody) and CD140 (anti-fibroblast transmembrane glycoprotein antibody) expression between 3th and 16th passage to assess cell homogeneity. TUNEL technique and Annexin-V/PI staining in flow cytometry were used to detect keratinocyte apoptosis. We showed that Curcuma longa exerts a proapoptotic effect on pterygium-derived keratinocytes already after 3 h treatment. Moreover, after 24 h treatment, Curcuma longa induces a significant increase in TUNEL as well as Annexin-V/PI positive cells in comparison to untreated samples. Our study confirms previous observations highlighting the expression, in pterygium keratinocytes, of nuclear VEGF and gives evidence for the first time to the expression of nuclear and cytoplasmic VEGF-R1. All in all, these findings suggest that Curcuma longa could have some therapeutic potential in the treatment and prevention of human pterygium.

Iatrogenic Bleb Formation and Hypotony Maculopathy Following Pterygium Surgery with Mitomycin-C

Purpose:

To report a case of late iatrogenic bleb formation and hypotony maculopathy after pterygium surgery applying Mitomycin C (MMC).

Case Report:

A 66-year-old man presented with an elevated, bleb-like, fluid-filled, cystic lesion on the nasal sclera of the right eye. The patient had undergone pterygium surgery with a combination of conjunctival autograft and adjuvant intraoperative MMC 0.02% four years before. The sclera seemed fistulized at the site of surgery and a thin layer of conjunctiva completely covered the lesion. A scleral patch graft was secured over the fistula with sutures, followed by excision of the thinned, avascular conjunctiva and advancement of the healthy adjacent conjunctiva to cover the patch graft. One month later, a small bleb re-appeared adjacent to the scleral patch graft and IOP was 2 mmHg. Argon-laser treatment of the bleb was tried to induce scarring and reduction of bleb size, and was highly effective. After one week, IOP was increased to 8 mmHg. The clinical features remained stable four months after initial presentation.

Conclusion:

Pterygium surgery using adjuvant MMC may result in late iatrogenic bleb formation and hypotony maculopathy. This complication can be successfully corrected surgically using a scleral patch graft combined with argon laser treatment over the inadvertent bleb.

Clinical features and visual outcomes of scleritis patients presented to tertiary care eye centers in Saudi Arabia

AIM

To describe the clinical features, systemic associations, treatment and visual outcomes in Saudi patients with scleritis.

METHODS

A retrospective chart review was performed for patients with scleritis presenting to two tertiary care eye hospitals in Riyadh, Saudi Arabia, from 2001 to 2011. Data were collected on the clinical features of scleritis, subtypes of scleritis, associated systemic disease, history of previous ocular surgery and medical therapy, including the use of immunosuppressants. Treatment outcomes were evaluated based on best-corrected visual acuity (BCVA) and response to treatment.

RESULTS

Of the 52 patients included in the study, non-necrotizing anterior scleritis was the most common type of scleritis in 22 patients (42.3%), followed by posterior scleritis in 14 patients (26.9%). The majority of cases, 31 patients (59.6%), were idiopathic in nature. Systemic associations were present in 12 patients (23.1%). Infectious scleritis was confirmed in 6 patients (11.5%): 3 with bacterial scleritis after pterygium excision, 2 patients with scleritis related to tuberculosis and 1 patient with scleritis resulting from herpes simplex infection. For the various subtypes of scleritis, BCVA values after treatment and time to remission significantly differed (P<0.05, all cases). Systemic immunosuppressive therapies in addition to steroids were administered to 46.2% of all patients. The T-sign was present on B-scan ultrasonography in 9 (64.3%) of the 14 posterior scleritis patients.

CONCLUSION

Non-necrotizing anterior scleritis was the most common subtype of scleritis. Final visual outcome and time to remission differed among the various scleritis subtypes.

Postoperative necrotizing scleritis: a report of four cases

Postoperative necrotizing scleritis should be considered in cases of persistent localized postoperative inflammation following all forms of surgical trauma. We present the history, clinical findings, and follow-up data of four patients with postoperative necrotizing scleritis. The clinical records of four patients who developed scleritis following ocular surgery were retrospectively reviewed. The first step in managing necrotizing scleritis is to rule out infectious etiology. Surgically induced necrotizing scleritis is an immune-mediated condition that can coexist with concomitant infectious condition, i.e. endophthalmitis, but response to immunosuppression leads to resolution of the disease and verifies the diagnosis.