Necrotizing scleritis after strabismus surgery in thyroid eye disease

Update on the surgical management of Graves' orbitopathy

Graves' orbitopathy (GO) is a complex autoimmune disorder of the orbit that causes the eye to appear disfigured. GO is typically associated with Graves' disease, an inflammatory autoimmune condition that is caused by thyrotropin receptor autoantibodies. Although our knowledge of the pathophysiology of GO has improved, its exact pathogenesis remains unclear. Some patients suffer from disfigurement, double vision, and even vision loss rather than hyperthyroidism. The disease severity and activity prompt different treatments, as the signs of GO are heterogeneous, so their management can be very complex. Despite medical advances, the first-line treatment for moderate-to-severe active GO is still glucocorticoids, while surgery can be critical for the treatment of chronic inactive GO. Surgery is sometimes required in the acute phase of the disease when there is an immediate risk to vision, such as in dysthyroid optic neuropathy. Most surgeries for GO are rehabilitative and subdivided into three categories: decompression, strabismus repair, and lid surgery. This review is a basic overview of the field, with up-to-date knowledge of the surgical techniques for GO. We review and summarize recent literature on the advances in surgery for GO to provide up-to-date insights on the optimal surgical treatment for GO.

Preserved corneal lamellar transplantation for infectious and noninfectious scleral defects: Three case reports and literature review

RATIONALE

: Reinforcement of thinned or necrotizing sclera has been conducted using various materials, including allogeneic sclera, allogenic cornea, amniotic membrane, fascia lata, pericardium, periosteum, and perichondrium. Among them, good outcomes have traditionally been obtained using preserved scleral grafts. However, scleral patch grafts have complications such as graft retraction, thinning, dehiscence, and necrosis. Furthermore, to promote epithelial healing, scleral patch grafting must be accompanied by procedures such as amniotic membrane transplantation (AMT) or grafting using conjunctival flaps or autografts. Recently, acellular preserved human corneas have been used in various ophthalmic surgeries, with emerging evidence supporting its use for treating scleral defects as an option that does not require AMT or conjunctival autografting. We investigated whether corneal patch grafting would show wound healing and tectonic success rate outcomes comparable to those of existing techniques.

PATIENT PRESENTATION

: Three patients presented with intractable ocular pain. Slit-lamp examination showed marked scleral thinning at the nasal side.

DIAGNOSIS

: Scleral thinning progressed with conservative treatment; microbial staining and culturing were performed. Infectious or non-infectious scleritis was diagnosed according to slit-lamp examination and microbial culture results.

INTERVENTIONS

: A preserved corneal lamellar patch was grafted at the scleral thinning area.

OUTCOMES

All patients achieved tectonic success with reduction of inflammation following corneal patch grafting. Two patients achieved complete re-epithelialization within 7 days, while 25 days were required for the third patient. No patients experienced graft thinning, rejection, or infection.

LESSONS

: Our report suggests the feasibility of using acellular preserved human cornea patch grafts to reinforce inflammatory scleral defects and obtain successful outcomes in terms of wound healing. This technique shows a comparable tectonic success rate and superior effect on scleral defect healing without the need for adjunctive AMT or conjunctival autografting.

Necrotizing scleritis following uncomplicated strabismus surgery

A 5-year-old child having infantile esotropia with bilateral inferior oblique over action underwent uncomplicated strabismus surgery. On the first postoperative day, the child was orthophoric but on day 10, the child was brought with the complaints of severe pain and redness along the original insertion of left medial rectus muscle. Immediate medical management was initiated after appropriate microbiological sampling. Subsequently, on day 13, patient developed sudden discomfort after a bout of violent cough followed by severe pain and discomfort. Slit-lamp examination confirmed the scleral wound dehiscence with vitreous prolapse for which early scleral patch graft within 6 h was performed to achieve optimal visual and cosmetic outcomes.

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.

Preserved Corneal Lamellar Grafting Reduces Inflammation and Promotes Wound Healing in a Scleral Defect Rabbit Model

Purpose

To investigate the effect of preserved corneal lamellar grafting on inflammation and wound healing and to compare its effect with that of preserved scleral grafting in a scleral defect rabbit model.

Methods

New Zealand White rabbits were assigned to a corneal lamellar grafting group (n = 5) or a scleral grafting group (n = 5). After lamellar dissection of superotemporal sclera using 6.0-mm trephine, the same sizes of preserved human corneal or scleral grafts were transplanted with 10-0 nylon interrupted sutures. The grafted areas were photodocumented at 3 to 21 days after surgery to evaluate epithelial wound healing index (%), neovascularization and presence of filaments. The existence of CD3⁺ T cells and CD34⁺ cells at the grafted areas was analyzed at 21 days.

Results

Epithelial wound healing index was significantly higher in the corneal grafting group at 9 days (P < 0.05). Scleral grafts showed copious formation of filaments adherent to the engrafted area from 9 to 14 days, whereas the corneal grafts were free of filaments. The numbers of inflammatory cells were significantly higher in the scleral grafts (P < 0.05), and CD3⁺ T cells and CD34⁺ cells were populated within inflammatory cells at graft-recipient junctions in both groups. The mean areas of the estimated perigraft and intragraft neovascularization tended to be higher in scleral grafts.

Conclusions

Preserved corneal lamellar grafting enhances epithelial wound healing and alleviates inflammation in a scleral defect rabbit model.

Translational Relevance

This work suggests that the preserved corneal graft may be considered as a favorable alternative option for repairing scleral defects.

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.