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The many faces of surgically induced necrotising scleritis – A case series
*Corresponding author: Hariom Subhashchandra Yadav, Department of Ophthalmology, M and J Western Regional Centre of Ophthalmology, Ahmedabad, Gujarat, India. hariomy26@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Yadav HS, Bhole PK, Parmar DP. The many faces of surgically induced necrotising scleritis – A case series. Global J Cataract Surg Res Ophthalmol. doi: 10.25259/GJCSRO_37_2025
Abstract
Surgically induced necrotising scleritis (SINS) is a rare but severe complication following ocular surgery. This case series highlights the importance of early recognition and management of SINS to prevent complications such as scleral perforation and loss of vision. It also underscores the need for a multidisciplinary approach, including a thorough systemic and microbiological evaluation, to rule out underlying autoimmune or infectious causes in such cases and a need for immunosuppression and surgical intervention in selected recalcitrant cases along with medical management.
Keywords
Autoimmune
Immunosuppression
Infectious
Scleral perforation
Surgical intervention
Surgically induced necrotising scleritis
INTRODUCTION
Surgically induced necrotising scleritis (SINS) is a rare local autoimmune reaction of the sclera typically presenting postoperatively as a focal area of intense scleral inflammation adjacent to the site of previous surgical incision. The exact cause of SINS remains unknown; hypersensitivity reaction directed against an antigen exposed or altered after surgical insult or ischaemia may play an important role.[1] Ocular trauma serves as a triggering factor that can initiate scleral necrosis through various pathogenic pathways. Patients with SINS usually have an atypical response to surgical trauma which can be attributed to the presence of unusual local and systemic immunological factors.[2,3]
Ocular surgeries that have been associated with SINS include cataract extraction, trabeculectomies, strabismus corrective procedures, scleral buckles, pars plana vitrectomies and pterygium surgeries.[4,5] This case series aims to describe the clinical presentation, management and outcome of patients with SINS in different scenarios in the absence of systemic disease.
CASE SERIES
Case 1
A 62-year-old male presented with severe pain, redness and watering in the left eye (LE) 3 weeks post small incision cataract surgery (SICS) with rigid polymethyl methacrylate intraocular lens (IOL) implantation with scleral tunnel sutured with 10/0 interrupted polyamide non-absorbable sutures. Visual acuity LE was unaided 6/9. Slit lamp examination revealed LE 3.5 × 2 mm area of scleral melt adjacent to an exposed scleral incision with loose sutures with clear cornea and pseudophakia [Figure 1]. Fundus and ultrasonography (B scan) of the LE revealed normal posterior segment. Scleral scraping from the affected area was sent for microbiological examination (Gram staining and potassium hydroxide (KOH) preparation along with bacterial and fungal culture) to rule out local infection. The scraping report was negative, thereby ruling out local infection. Systemic/autoimmune diseases were ruled out by systemic investigations like Mantoux test, and blood tests include a routine haemogram, erythrocyte sedimentation rate [ESR], serum rheumatoid factor [RA], antinuclear antibodies [ANA], human leucocyte antigen B27 [HLAB27], antineutrophilic cytoplasmic antibodies [ANCA], tuberculin skin test and chest X-ray. On consultation with the operating surgeon, the possibility of excessive use of cautery post-conjunctival peritomy during SICS was suspected and a diagnosis of SINS was made.
- (A) 3.5 × 2 mm area of scleral melt adjacent to exposed scleral incision. (B) Complete conjunctivalisation of area of scleral melt.
The patient was started on topical steroid (prednisolone acetate 1%) 6 times/day along with topical antibiotic (moxifloxacin 0.5%) 4 times/day, cycloplegic (cyclopentolate 1% w/v) twice a day, lubricants and a weekly tapering dose of systemic corticosteroid (T. Prednisolone 1 mg/kg) with oral non-steroidal anti-inflammatory agent (T. Diclofenac Sodium 50 mg twice a day). Loose sutures were removed and sent for culture which turned out to be negative for infection. After 4 weeks, complete conjunctivalisation of area of scleral melt was seen with restoration of visual acuity of 6/9 (unaided).
Case 2
A 65-year-old female presented with LE pain, redness and foreign body sensation 2 weeks post pars plana vitrectomy with scleral fixated intraocular lens (SFIOL), which was done for LE dropped nucleus and aphakia post SICS. Postoperative best corrected visual acuity was 6/12. On slit-lamp evaluation, an area of scleral melt (6 mm × 3 mm) with exposed haptic of the SFIOL was seen nasally. Rest anterior segment was normal and fundus was also within normal limits. Local infection was ruled out by microbiological examination of scleral scraping of the affected area. Systemic investigations such as routine haemogram, ESR, serum RA factor, ANA, HLA B27, ANCA, tuberculin skin test and chest X-ray were done and systemic disorders were also ruled out. Treatment for non-infectious scleritis was started with topical antibiotic (moxifloxacin 0.5%) eye drop, a mild steroid (fluorometholone acetate 0.1% eye drops), cycloplegic (cyclopentolate 1%w/v) twice a day, lubricants and a 3-day course of pulsed systemic steroid therapy, followed by weekly tapering of oral prednisolone (1 mg/kg/ day) after consultation with a physician. However, with no improvement in scleral melt, a heterologous scleral patch graft with amniotic membrane layer with fibrin glue was performed undercover of systemic steroids (T. Prednisolone 1 mg/kg in a tapering course every 7 days), resulting in vascularisation of the sclera within 3 weeks [Figure 2].
- (A) Scleral melt (6 mm × 3 mm) with exposed haptic of the scleral fixated intraocular lens. (B) Completely vascularised scleral area with heterologous scleral patch graft.
Case 3
A 64-year-old female patient presented with excruciating pain, redness and watering in the right eye (RE), after 9 years of scleral buckle surgery for high bullous retinal detachment. She had a history of cataract extraction with IOL 12 years ago. Visual acuity RE was counting finger 3 m. On slit lamp evaluation, mucopurulent discharge with an area of scleral melt of approximately 20 mm × 8 mm, adjacent to exposed scleral buckle, 8 mm lateral to the temporal limbus was seen. The cornea was clear with anterior chamber deep and pseudophakia. Fundus was 0.4–0.5 cup–disc ratio with mild disc pallor, cryo marks present temporally and ultrasonography B scan showed anechoic posterior segment. Loose suture and scleral buckle were removed and sent for culture, which was positive for methicillin-sensitive Staphylococcus aureus sensitive to penicillin, amikacin and vancomycin. Systemic/autoimmune diseases were ruled out by systemic investigations (routine haemogram, ESR, serum RA factor, ANA, HLA B27, ANCA, serologies for syphilis, tuberculin skin test and chest X-ray). The patient was started on topical antibiotics fortified amikacin 2.5% and vancomycin 5% eye drop 6 times a day (based on culture and sensitivity report), cycloplegic (cyclopentolate 1% w/v) twice a day along with lubricants and systemic antibiotic tablet amoxicillin 500 mg with clavulanic acid 125 mg thrice a day. After 6 weeks of medical management, vascularisation of the sclera was seen with conjunctivalisation [Figure 3].
- (A) 20 × 8 mm area of scleral melt. (B) Vascularised scleral area after 6 weeks of medical management.
DISCUSSION
Scleral necrosis and melting are infrequent sequelae of ocular surgeries, with potentially devastating ocular consequences. Surgical trauma can trigger the immune complex-mediated vasculitis in a predisposed patient. At the site of trauma or injury, circulating immune complexes accumulate in the episcleral vessels and perforate the scleral vessels, leading to scleral destruction through inflammatory microangiopathy. Identification of SINS is essential as early institution of intensive steroid therapy is needed. In non-responsive cases, immunosuppressives may also be instituted. Besides, any future ocular surgery in these patients may predispose to recurrent necrotising inflammation at the wound sites.[6]
In accordance with the previously reported case series, the latency period between the diagnosis of SINS and ocular surgery was highly variable (ranging from 2 weeks to 9 years post-scleral buckling). A long latency has been noted previously in patients after strabismus and pterygium excision surgery.[4,5,7]
SINS has been reported after a wide variety of ocular surgeries, Pterygium excision, being the most common association, retinal detachment surgery, cataract surgery and even procedures like diode laser and intravitreal injections.[1,5] The present case series reports a case of SINS after SFIOL surgery, which to the best of our knowledge has not been yet reported. The likely cause in Case 1 might be excessive cauterisation of the conjunctiva adjacent to the scleral incision in SICS causing localised ischaemia. In Case 2, a history of multiple procedures with excessive cauterisation adjacent to scleral flaps created for SFIOL tucking might have been the culprits. Whereas in Case 3, it might be due to multiple surgeries with tight encirclage with band buckle and localised infection.
Systemic diseases such as rheumatoid arthritis and granulomatosis with polyangiitis are the common systemic diseases that are associated with scleritis and have been reported in patients with SINS too.[8] However, no systemic disease was noted in our patients.
Infection (e.g., Pseudomonas, S. aureus) may directly damage scleral tissue or activate immune responses, leading to scleral ischaemia and necrosis. Case 3 had infectious SINS which resolved with medical management. Hence, a prompt microbiological examination is extremely essential to effectively manage such cases. In recalcitrant cases, multilayer amniotic membrane grafting with fibrin glue or scleral grafting can be tried.[8] Casas et al. reported that combination of tenonplasty and amniotic membrane transplantation with or without lamellar corneal patch graft, using sutures or fibrin glue, to be a feasible alternative for treating scleral ischaemia and/or melt.[9] King and Rotchford described the use of a scleral micro-patch graft and fibrin glue to treat scleral flap defects following trabeculectomy.[10]
This being a retrospective case series with a small sample size of three cases has certain limitations of lack of a long follow-up of the patients to study complications and recurrence.
CONCLUSION
SINS is an uncommon but significant complication of ocular surgery that demands early detection and swift treatment to avoid severe vision impairment and preservation of globe integrity. A comprehensive systemic assessment is crucial to exclude underlying infectious or autoimmune causes contributing to the condition. Prompt initiation of systemic immunosuppression in selected cases, after ruling out infection, is critical for achieving a favourable visual prognosis.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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