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CASE REPORT
Year : 2020  |  Volume : 32  |  Issue : 3  |  Page : 295-298

Scleral patch graft as a rescue for infectious scleritis


Little Flower Hospital and Research Centre, Angamaly, Kerala, India

Date of Submission21-Mar-2020
Date of Acceptance23-Apr-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. Hilda K Nixon
C/o M. T Joseph, #40, Meleppuram House, Haritha Nagar, Potta P. O., Chalakudy, Thrissur District - 680 722, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_35_20

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  Abstract 


We report a case of a 68-year-old male who presented with redness and pain in the right eye with a previous history of pterygium surgery with mitomycin-C in the same eye 2 weeks before onset of symptoms. On examination, visual acuity in the right eye was counting fingers at 2 m improving to 6/24 with pinhole and the left eye was 6/18 improving to 6/12 with pinhole. Right eye showed signs of melting in the nasal sclera with avascularity and perilimbal corneal infiltrate. Scraping was done and culture showed growth of Fusarium species. The patient was started on antifungal drops, and a scleral patch graft was done with multilayered amniotic membrane graft with fibrin glue. On follow-up, the patient showed symptomatic improvement with vascularization of scleral graft and vision improved following cataract surgery.

Keywords: Amniotic membrane graft, Fusarium, infectious scleritis, sclera patch graft, scleral melt


How to cite this article:
Nixon HK, Bhat L, Pudukadan D, William NC. Scleral patch graft as a rescue for infectious scleritis. Kerala J Ophthalmol 2020;32:295-8

How to cite this URL:
Nixon HK, Bhat L, Pudukadan D, William NC. Scleral patch graft as a rescue for infectious scleritis. Kerala J Ophthalmol [serial online] 2020 [cited 2021 Apr 22];32:295-8. Available from: http://www.kjophthal.com/text.asp?2020/32/3/295/304552




  Introduction Top


Scleral melting is a well-reported complication after pterygium excision,[1] especially with the adjunctive use of mitomycin-C[2] as a result of prolonged inhibition of wound healing with its antiproliferative action. Surgically induced necrotizing scleritis has been reported to occur after trabeculectomy, cataract extraction, retinal detachment surgery, and squint surgery. It presents as a focal area of intense inflammation of the sclera, adjacent to the site of previous scleral or limbal incision.[3]

Nearly 50% of scleritis cases are associated with collagen vascular disease, and an infectious etiology is uncommon. Pseudomonas aeruginosa is the most common organism associated with scleral and corneal melting. However, fungi are more commonly implicated in the tropical regions of India.[4]

Reinforcement of thin or perforated sclera is necessary, to prevent prolapse of ocular contents and secondary infection. Since sclera is avascular, it is well tolerated with minimal inflammatory reaction, and also, its natural curvature allows it to blend well with host sclera. On the other hand, lack of vascularity of the sclera will cause necrosis and sloughing and results in failure of scleral homografts.[5] Therefore, an overlying epithelial cover is essential to facilitate epithelialization and vascularization of the scleral graft and incorporation into host tissue.

We report a rare case of infectious scleritis with melting; postmitomycin-C treatment and through this report, we would like to emphasize the importance of early detection and early intervention in the management of infectious scleritis.


  Case Report Top


A 68-year-old male presented with a history of redness and pain in the right eye. The clinical records of the patient showed that he had previously undergone pterygium excision using adjunctive mitomycin-C in the right eye 2 weeks before onset of symptoms. the patient was on topical prednisolone acetate 1% drops 6 times per day and moxifloxacin 0.05% 4 times/day. He also underwent trabeculectomy in the left eye.

On examination, visual acuity in the right eye was counting fingers at 2 m improving to 6/24 with pinhole and the left eye was 6/18 improving to 6/12 with pinhole.

Right eye showed lid edema with mucopurulent discharge, intense congestion with engorged episcleral vessels in the nasal quadrant. Nasal sclera (previous surgical site) showed avascularity and signs of melting measuring 5 mm × 3 mm with the absence of overlying conjunctiva [Figure 1] with perilimbal corneal infiltrate adjacent to the area of thinning. Keratic precipitates were seen over endothelium along with anterior chamber cells (Grade 3) and flare seen. Lens showed nuclear sclerosis Grade 3 with posterior subcapsular cataract. Anterior vitreous phase was normal, and on fundus examination, media were hazy due to cataract. B scan of the right eye showed choroidal detachment in all quadrants with attached retina and no signs of vitritis [Figure 2]. Left eye showed well-formed bleb with moderate vascularization with patent peripheral iridotomy. Lens showed nuclear sclerosis Grade 2 with posterior subcapsular cataract. Fundus showed glaucomatous cupping with cup/disc of 0.8:1 and normal macula. Intraocular pressure was 4 mmHg in the right eye and 14 mmHg in the left eye using applanation tonometry.
Figure 1: Scleral melt at the site of pterygium excision with perilimbal corneal infiltrate

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Figure 2: B scan of right eye showing choroidal detachment

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The patient was admitted, gentle scraping was done, and empirical antimicrobial treatment was started. KOH showed fungal hyphae. In culture, Fusarium species was identified with moderate growth. The patient was admitted and started on the right eye natamycin 5% 1 hourly, voriconazole 1% 1 hourly, fluconazole 0.1% 1 hourly, amphotericin B 1 hourly, dorzolamide and timolol combination twice daily, moxifloxacin 4 times daily, and lubricants and systemic ketoconazole 200 mg twice daily. In the left eye, his topical antiglaucoma medications were continued. However, the patient showed worsening of symptoms with the progression of scleral thinning. The risk and benefits of surgical intervention were explained to the patient. Patient underwent right eye scleral patch graft and multilayered amniotic membrane graft (AMG) with fibrin glue [Figure 3].
Figure 3: Scleral patch graft with overlying amniotic membrane graft

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At 1 week follow-up, the patient was symptomatically better. Corneal peripheral infiltrate decreased, and scleral patch graft was well attached. Graft edges showed signs of vascularization [Figure 4]. Overlying amniotic membrane was intact, and his medications were continued.
Figure 4: Scleral graft showing signs of vascularization in the periphery

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At 1 month of followup, corneal infiltrate resolved, with no signs of anterior uveitis. Scleral patch graft showed increased vascularity and overlying AMG slowly disintegrated. Antifungal medications were slowly tapered and stopped after 3 months.

At 6 months, the patient showed remarkable improvement with conjunctivalization of the scleral graft and scarring of the perilimbal corneal and anterior stroma [Figure 5]. There was resolution of choroidal detachment on B scan.
Figure 5: Total vascularization of scleral graft at 6 months

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The follow-up examination at 1 year revealed that the scleral patch graft was successful in maintaining the integrity of the globe and cataract surgery (phacoemulsification) with intraocular lens implantation done. Postoperative best-corrected visual acuity (BCVA) vision improved to 6/9.

At 3 years of follow-up, BCVA of 6/9 was maintained in the right eye and the scleral patch graft was healthy and vascularized [Figure 6].
Figure 6: Scleral patch graft at 3 years of follow-up

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  Discussion Top


An infective scleritis after any ophthalmic surgery is a serious threat to vision and integrity of the globe. Infectious scleritis is often misdiagnosed and initially managed as autoimmune scleritis. However, in all such cases, an underlying immune etiology should be ruled out. Thus, the overall visual outcome is worsened both due to delay in diagnosis and due to aggressive nature of associated microbes. A complete microbiological workup is needed to rule out any infectious etiology.

In our patient, culture report showed Fusarium species. The use of intraoperative mitomycin-C on bare sclera, aggressive cautery, and postoperative topical corticosteroids following pterygium excision could have been the cause of rapid progression of scleritis with secondary infection. Fungal scleritis responded to the treatment following surgical removal of the debris and necrotic tissue, discontinuation of corticosteroids, and aggressive antifungal therapy, both systemic and topical.

Debridement of the necrotic tissue helps in reduction of the infective load. A scleral patch graft has proven to be an effective method of closing the scleral defect.[6]

The scleral patch graft was successful in our case in restoring the anatomic integrity of the globe and facilitating visual outcome. Prior medical management with prompt surgical intervention and close follow-up is required to prevent recurrence and further devastating complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alsagoff Z, Tan DT, Chee SP. Necrotising scleritis after bare sclera excision of pterygium. Br J Ophthalmol 2000;84:1050-2.  Back to cited text no. 1
    
2.
Lu L, Xu S, Ge S, Shao C, Wang Z, Weng X, et al. Tailored treatment for the management of scleral necrosis following pterygium excision. Exp Ther Med 2017;13:845-50.  Back to cited text no. 2
    
3.
Gokhale NS, Samant R. Surgically induced necrotizing scleritis after pterygium surgery. Indian J Ophthalmol 2007;55:144-6.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Pradhan ZS, Jacob P. Infectious scleritis: Clinical spectrum and management outcomes in India. Indian J Ophthalmol 2013;61:590-3.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Lee JS, Shin MK, Park JH, Park YM, Song M. Autologous advanced tenon grafting combined with conjunctival flap in scleromalacia after pterygium excision. J Ophthalmol 2015;2015:547276.  Back to cited text no. 5
    
6.
Sangwan VS, Jain V, Gupta P. Structural and functional outcome of scleral patch graft. Eye (Lond) 2007;21:930-5.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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