Different management strategies of scleral necrosis

Ruchi Shukla; Anjum Mazhari; Ashutosh Kumar Mishra

doi:10.4103/jcor.jcor_46_21

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Year : 2022 | Volume : 10 | Issue : 1 | Page : 46-48

Different management strategies of scleral necrosis

Ruchi Shukla¹, Anjum Mazhari², Ashutosh Kumar Mishra³
¹ Department of Ophthalmology, Heritage Institute of Medical Sciences, Varanasi, India
² Indira Gandhi Eye Hospital and Research Center, Lucknow, Uttar Pradesh, India
³ Department of Neurology, AIIMS, Raebareli, Uttar Pradesh, India

Date of Submission	25-Mar-2021
Date of Decision	25-Aug-2021
Date of Acceptance	04-Sep-2021
Date of Web Publication	3-Feb-2022

Correspondence Address:
Ruchi Shukla
Flat No 5C, Type 2A, AIIMS, Munshiganj, Raebareli - 229 405, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcor.jcor_46_21

Abstract

Surgically induced necrotizing scleritis is a rare complication of ocular surgeries. Mitomycin C (MMC) when used intraoperatively may be related to serious postoperative complications. We report management of two cases in which patients underwent pterygium excision with adjunctive use of MMC and they both developed scleral necrosis. In the first case, scleral patch grafting was performed, while the other case underwent advanced Tenon's flap with a sliding conjunctival flap. Tectonic coverage can be done by various methods such as scleral patch grafting and advanced Tenon's flap and both provide structural and functional stability to eyes with scleral defects.

Keywords: Mitomycin C, scleral patch, Tenon's flap

How to cite this article:
Shukla R, Mazhari A, Mishra AK. Different management strategies of scleral necrosis. J Clin Ophthalmol Res 2022;10:46-8

How to cite this URL:
Shukla R, Mazhari A, Mishra AK. Different management strategies of scleral necrosis. J Clin Ophthalmol Res [serial online] 2022 [cited 2023 Jun 2];10:46-8. Available from: https://www.jcor.in/text.asp?2022/10/1/46/337193

Several surgical techniques are available for treating pterygium, such as bare sclera, simple conjunctival closure, and conjunctival autografts. Adjunctive therapies, such as postoperative beta radiation or thiotepa drops and intraoperative mitomycin C (MMC), can be used to prevent the recurrence of pterygium.^[1] Surgically induced necrotizing scleritis typically presents postoperatively as a focal area of intense scleral inflammation occurring adjacent to the site of previous scleral or limbal incision.^[2] Technically easier and therefore widely applied adjunct with primary pterygium excision is MMC.^[3] Scleral necrosis in cases of intraoperative MMC usage occurs due to the prolonged inhibition of wound healing. Reinforcement of attenuated sclera is necessary, especially when there is a uveal show to prevent prolapse of ocular contents and secondary infection. The purpose of this report is to present cases of scleral necrosis after pterygium surgery with intraoperative MMC administration and discuss various management strategies.

Case Reports

We analyzed two patients who were referred to our cornea services with scleral necrosis which developed after pterygium excision with intraoperative application of MMC.

Case 1

A 27-year-old male, farm laborer, had undergone a primary nasal pterygium excision at another institution with bare sclera technique with adjunctive intraoperative application of MMC 0.02% placed on the scleral bed for 3 min in the right eye. Twenty days postoperatively, he developed pain and redness in the operated eye.

On the first presentation, visual acuity was 6/6 in both eyes on Snellen chart.

On ocular examination, scleral necrosis (6 mm × 3 mm) with uveal show at 3 o'clock in the right eye was noted [Figure 1]a.

Figure 1: (a) Preoperative photograph of case 1 showing scleral necrosis (6 mm × 3 mm) with uveal show at 3 o'clock in the right eye. (b) Postoperative photograph at day 1. (c) Postoperative photograph at week 1 showing scleral patch graft was well taken up. (d) Postoperative photograph at 3 months

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Complete blood count, electrolytes, and inflammatory markers were all within normal ranges.

Antineutrophil cytoplasmic antibody, C-reactive protein, immunoglobulins (Ig) G, A, and M, uric acid, rheumatoid factor, antinuclear antibody, and anti-double-stranded DNA were performed which were all reported negative.

Donor scleral patch graft was fashioned to appropriate size and thickness. The graft was then secured to the edges of the resection site using 10-0 nylon sutures. The repaired sclera was then covered with a surrounding conjunctival tissue [Figure 1]b.

Topical 1% prednisolone (4 times daily, Alcon, India), 0.5% moxifloxacin (6 times daily, Alcon, India), and artificial tears (6 times daily, Alcon, India) with oral doxycycline 100 mg (BD, Cipla, India) were prescribed and gradually tapered over 1 month.

Scleral patch graft was well taken up on week 1 [Figure 1]c and the patient was kept on artificial tears (4 times daily, Alcon, India) and followed up for 3 months [Figure 1]d.

Case 2

A 31-year-old male, farm laborer by profession, presented to our cornea services with complaints of moderate pain and a black dot in his right eye for 10 days. The patient had undergone a primary nasal pterygium excision at another institution with bare sclera technique with adjunctive intraoperative application of MMC 0.02% placed on the scleral bed for 3 min in the right eye 3 months ago.

Complete blood count, electrolytes, and inflammatory markers were within normal ranges. Immunological testing did not reveal positive results for any collagen vascular disease and autoimmune disease. His best-corrected visual acuity was 6/6 in both eyes.

Slit-lamp examination of the right eye revealed at 3 o'clock there was a 7 mm × 3 mm scleral defect with 30% thinning with the uveal tissue show through it with Tenon hypertrophy in the right eye [Figure 2]a.

Figure 2: (a) Preoperative photograph showing 7 mm × 3 mm scleral defect with 30% thinning with the uveal tissue show through it with Tenon hypertrophy in the right eye. (b) Postoperative photograph a 6 months

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Intraoperatively 30% scleral melt with a pyogenic granuloma was seen extending over the medial rectus which was excised and multilayered amniotic membrane grafting was done to cover the defect. This was covered completely by the adjacent healthy upper and lower nasal advanced Tenon flap, and then, sliding bulbar conjunctival flap was made from healthy adjacent conjunctiva and fixed with vicryl 8-0 interrupted sutures to prevent wound dehiscence between the conjunctival and scleral tissue by ocular movement. The patient was started on topical 1% prednisolone (4 times daily, Alcon, India), 0.5% moxifloxacin (6 times daily, Alcon, India), and artificial tears (6 times daily, Alcon, India) with oral doxycycline 100 mg (BD, Cipla, India) which were prescribed and gradually tapered over 1 month. The patient was followed up for 6 months [Figure 2]b.

Discussion

Incidence of scleral necrosis after pterygium surgery has been reported to be 0.2%–4.5%.^[4]

MMC-induced complications are associated with ocular surface inflammation. Therefore, our goal was to restore the scleral integrity and also control the ocular surface inflammation with corticosteroids and tetracyclines.

In literature, various donor materials have been used to provide tectonic covering, but the most common tissue is preserved sclera. In our first case, we used scleral patch graft as it is the most common tissue and it has a natural curvature allowing it to neatly blend with host scleral tissue.^[5] Another advantage of a scleral graft is that it is avascular and is well tolerated with little inflammatory reaction. However, the lack of vascularisation is a major disadvantage. Amniotic membrane has anti-inflammatory,^[6] antifibrotic, and epithelialization promoting properties but is not able to provide adequate tectonic rigidity and is prone to rapid loss of tissue. We attempted an advanced Tenon flap near the scleral thinning in our second case, as it has a better survival rate due to abundant vasculature as well as it is easily obtained from the patient itself. Another distinguishing advantage of Tenon tissue over the scleral graft is that relatively large scleral defects can be covered. We would recommend this technique for patients with small- to moderate-sized scleral thinning rather than those with large sized over 10 mm impending perforations or full-thickness perforations. In addition, we made a rotating conjunctival flap over the advanced Tenon flap to provide epithelial coverage and to minimize the risk of postoperative graft failure. Moreover, full reconstruction of ocular integrity and the conjunctival surface also results in excellent cosmetic outcomes.

Conclusion

Our clinical results stress upon that both scleral graft and Tenon flap provide adequate functional and structural stability to eyes with scleral defects with bearable 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.

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