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Azar NS, Ruiz-Lozano RE, Quiroga-Garza ME, Soifer M, Mousa HM, Komai S, Leverenz DL, Perez VL. Delayed presentation of surgically induced scleral necrosis after I-BRITE procedure treated with immunosuppressive therapy. Digit J Ophthalmol 2023; 29:77-82. [PMID: 37780039 PMCID: PMC10539002 DOI: 10.5693/djo.02.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Surgically induced scleral necrosis (SISN) is an uncommon complication of ocular procedures. Cosmetic eye-whitening surgery involves conjunctival and Tenon's capsule dissection, cautery, and mitomycin C application. We report the case of a 36-year-old white woman referred to our clinic for severe pain, scleral inflammation, and necrosis in both eyes 9 years after I-BRITE, an elective eye-whitening procedure. An extensive workup yielded negative results. The patient improved with aggressive lubrication and topical and high-dose systemic prednisone (60 mg), with recurrence upon steroid tapering. Concomitant weekly methotrexate was added, resulting in inflammatory control and allowing discontinuance of topical and oral steroids.
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Affiliation(s)
- Nadim S. Azar
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Raul E. Ruiz-Lozano
- Tecnologico de Monterrey, School of M and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico
| | - Manuel E. Quiroga-Garza
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Matias Soifer
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Hazem M. Mousa
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Seitaro Komai
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - David L. Leverenz
- Department of Medicine, Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina
| | - Victor L. Perez
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
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2
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Yu J, Syed ZA, Rapuano CJ. Infectious Scleritis: Pathophysiology, Diagnosis, and Management. Eye Contact Lens 2021; 47:434-441. [PMID: 34224444 DOI: 10.1097/icl.0000000000000813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Julia Yu
- Cornea Service, Wills Eye Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Ruiz-Lozano RE, Garza-Garza LA, Davila-Cavazos O, Foster CS, Rodriguez-Garcia A. The clinical and pathogenic spectrum of surgically-induced scleral necrosis: A review. Surv Ophthalmol 2021; 66:594-611. [PMID: 33422510 DOI: 10.1016/j.survophthal.2020.12.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Raul E Ruiz-Lozano
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico
| | - Lucas A Garza-Garza
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico
| | - Osvaldo Davila-Cavazos
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institute, Waltham, MA, USA; Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Alejandro Rodriguez-Garcia
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico.
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4
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Blitzer AL, Skondra D, Farooq AV. Scleritis and Retinal Detachment After Strabismus Surgery in a Patient With Thyroid Eye Disease. JAMA Ophthalmol 2020; 138:1209-1210. [PMID: 32940624 DOI: 10.1001/jamaophthalmol.2020.2034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Andrea L Blitzer
- Department of Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois
| | - Dimitra Skondra
- Department of Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois
| | - Asim V Farooq
- Department of Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois
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Pujari A, Chaniyara MH, Sharma P, Sharma N. Necrotizing scleritis following uncomplicated strabismus surgery. Indian J Ophthalmol 2020; 68:2555-2557. [PMID: 33120690 PMCID: PMC7774220 DOI: 10.4103/ijo.ijo_1839_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Amar Pujari
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | | | - Pradeep Sharma
- Professor of Strabismus and Pediatric Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Sharma
- Professor Cornea and Refractive Surgery, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Rath S, Ganesh S, Mathur U, Sharma M. Necrotizing scleritis after strabismus surgery in Treacher Collins syndrome. GMS OPHTHALMOLOGY CASES 2020; 10:Doc20. [PMID: 32676265 PMCID: PMC7332715 DOI: 10.3205/oc000147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Soveeta Rath
- Department of Pediatric Ophthalmology and Strabismus, Dr. Shroff's Charity Eye Hospital, Daryaganj, New Delhi, India
| | - Suma Ganesh
- Department of Pediatric Ophthalmology and Strabismus, Dr. Shroff's Charity Eye Hospital, Daryaganj, New Delhi, India
| | - Umang Mathur
- Department of Cornea and Anterior Segment Services, Dr. Shroff's Charity Eye Hospital, Daryaganj, New Delhi, India
| | - Manasvini Sharma
- Department of Pediatric Ophthalmology and Strabismus, Dr. Shroff's Charity Eye Hospital, Daryaganj, New Delhi, India
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Ram R. Tectonic corneal lamellar grafting for surgically-induced necrotizing scleritis after strabismus surgery: Case report & literature review. Am J Ophthalmol Case Rep 2018; 11:28-31. [PMID: 30062145 PMCID: PMC6063979 DOI: 10.1016/j.ajoc.2018.04.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 04/12/2018] [Accepted: 04/25/2018] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Radha Ram
- Texan Eye, 1700 S Mopac, Austin, TX, USA
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Kumar S, Ichhpujani P, Thakur S. Surgically Induced Scleral Necrosis in a Patient With Rheumatoid Arthritis After AGV Implantation. J Glaucoma 2018; 27:e55-e58. [DOI: 10.1097/ijg.0000000000000860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Food-Induced Red Eye. Optom Vis Sci 2017; 94:775-780. [DOI: 10.1097/opx.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Akbari MR, Mohebbi M, Johari M, Mirmohammadsadeghi A, Mahmoudi A. Multifocal Surgically Induced Necrotizing Scleritis Following Strabismus Surgery: A Case Report. Strabismus 2016; 24:101-5. [DOI: 10.1080/09273972.2016.1205104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Eraslan M, Toker E. Necrotizing scleritis after pterygium excision with fibrin glue–fixated conjunctival autograft in Behcet’s disease. Can J Ophthalmol 2016; 51:e116-e119. [DOI: 10.1016/j.jcjo.2016.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 03/21/2016] [Indexed: 11/30/2022]
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12
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The spectrum of postoperative scleral necrosis. Surv Ophthalmol 2013; 58:620-33. [DOI: 10.1016/j.survophthal.2012.11.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 10/30/2012] [Accepted: 11/01/2012] [Indexed: 11/18/2022]
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13
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Huang CY, Lin HC, Yang ML. Necrotizing scleritis after strabismus surgery in thyroid eye disease. J AAPOS 2013; 17:535-6. [PMID: 24160978 DOI: 10.1016/j.jaapos.2013.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 03/15/2013] [Accepted: 04/21/2013] [Indexed: 12/01/2022]
Abstract
Surgically induced necrotizing scleritis, which can lead to potentially devastating consequences, is a rare sequela to many types of ocular surgeries. We describe a 58-year-old woman who developed necrotizing scleritis following strabismus surgery for thyroid ophthalmopathy. Tectonic corneal patch grafting resulted in a favorable outcome.
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Affiliation(s)
- Chung-Ying Huang
- Department of Ophthalmology, Chang-Gung Memorial Hospital, Chang-Gung University, Taoyuan, Taiwan
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14
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Thatte S, Gupta L. Amniotic membrane transplantation in surgically induced necrotizing scleritis with peripheral ulcerative keratitis. Middle East Afr J Ophthalmol 2013; 19:419-21. [PMID: 23248548 PMCID: PMC3519133 DOI: 10.4103/0974-9233.102765] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A case of surgically induced necrotizing scleritis (SINS) after manual small incision cataract surgery that was associated with peripheral ulcerative keratitis (PUK) at a different site. Neither pathology responded to systemic steroids and progressed to become sight threatening, which is unusual. Progression of SINS was aggressive enough to cause a limbal wound gape, similarly PUK extended up to Descemet's membrane and emergency amniotic membrane transplantation (AMT) was required to save the globe. AMT may regress the scleral and corneal melting successfully. It is not common to observe SINS with PUK at a different site that is unresponsive to systemic steroids. AMT, though palliative treatment, was effective at treating this condition successfully.
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Affiliation(s)
- Shreya Thatte
- Department of Ophthalmology, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India
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15
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Scleral necrosis secondary to nonabsorbable suture following ptosis surgery. Ophthalmic Plast Reconstr Surg 2013; 29:e115-7. [PMID: 23274808 DOI: 10.1097/iop.0b013e3182785c01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a unique case of persistent scleral ulceration in a 68-year-old woman who developed eye redness, pain, and photophobia 2 days following external levator advancement with nonabsorbable suture. Slit-lamp biomicroscopy revealed an area of scleral ulceration superonasal to the limbus. The patient was treated with 6 months of topical steroids with some improvement in her condition but without complete resolution. An exposed suture or foreign body was never directly visualized; however, a mobile nodule was noted upon palpation of the eyelid. Subsequent surgical eyelid exploration revealed a retained polypropylene suture, which was dissected free and removed. Postoperatively, the area of scleral ulceration resolved completely.
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Excision of Granulation Tissue and Free Conjunctival Autograft in the Management of Necrotizing Scleritis. Cornea 2010; 29:577-9. [DOI: 10.1097/ico.0b013e3181b532e5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Tamhankar MA, Volpe NJ. Atypical necrotizing scleritis after strabismus surgery. J AAPOS 2008; 12:190-2. [PMID: 18083594 DOI: 10.1016/j.jaapos.2007.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 09/05/2007] [Accepted: 09/13/2007] [Indexed: 11/28/2022]
Abstract
An 88-year-old woman developed necrotizing scleritis after eye muscle surgery. Her initial clinical presentation suggested postoperative infection, but the inflammation continued to progress despite antimicrobial therapy. The scleritis completely resolved after initiation of systemic corticosteroids. Postoperative necrotizing scleritis is a rare complication that occurs at the site of previous ocular surgery. It occurs more frequently in women with underlying systemic autoimmune disease and after multiple ocular procedures. We report an unusual case of necrotizing scleritis with inflammation that occurred after strabismus surgery. A specific autoimmune disease was not identified.
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Affiliation(s)
- Madhura A Tamhankar
- Division of Neuro-ophthalmology, Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania 19104-2689, USA
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Abstract
PURPOSE This paper presents results of an analysis on patients operated on for strabismus in order to evaluate frequency and clinical characteristics of corneal alterations. In our experience, this kind of complication occurs more frequently after reoperation and/or after surgery for esotropia in sixth nerve palsy using transposition procedures. METHODS A retrospective analysis was made of 655 consecutive patients operated on for strabismus on the recti muscles with a limbal approach from January 2001 to July 2003 (30 months). RESULTS We found 30 corneal dellen out of the 184 eyes (16.30%) reoperated on medial rectus muscles, 7 corneal dellen out of the 37 eyes (18.92%) operated on using transposition procedures, 4 corneal dellen out of the 101 eyes (3.96%) operated of lateral rectus muscle recession combined with medial rectus muscle resection and no corneal dellen in the other 976 eyes operated of using different surgical procedures on the recti muscles. All patients had been operated on using a conjunctival limbal approach. All corneal dellen disappeared in about 10-15 days, using topical antibiotics and a firm bandage applied to the eye at night, leaving permanent alterations in corneal homogeneity in 8 eyes (19.51%). CONCLUSION This study showed that this kind of complication is relatively frequent after reoperations and/or transposition procedures, thus indicating that it is possible to identify surgical procedures which might play a role in the development of corneal dellen. Therefore, the post-operative monitoring of patients at risk should not be delayed for more than one week, in order to avoid possible corneal perforation.
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Affiliation(s)
- M Fresina
- Ophthalmology Service, Department of Surgery and Transplant A. Valsalva, University of Bologna, Bologna, Italy.
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Kearney FM, Blaikie AJ, Gole GA. Anterior necrotizing scleritis after strabismus surgery in a child. J AAPOS 2007; 11:197-8. [PMID: 17416330 DOI: 10.1016/j.jaapos.2006.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2006] [Revised: 08/30/2006] [Accepted: 09/03/2006] [Indexed: 10/23/2022]
Abstract
Anterior necrotizing scleritis is a rare but potentially devastating complication of ocular surgery that most often occurs after cataract surgery in elderly patients who may have an underlying systemic autoimmune condition(1) or, less likely, an infectious cause.(2) We describe the management and outcome of a case of bilateral anterior necrotizing scleritis after postoperative infection in a 19-month-old girl who had recently undergone strabismus surgery.
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Affiliation(s)
- Frances M Kearney
- Departments of Ophthalmology and Paediatrics & Child Health, Royal Children's Hospital, Brisbane, Queensland, Australia
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Lai T, Leibovitch I, Zadeh R, Chehade M, Tamblyn D, Selva D. Surgically induced necrotizing scleritis occurring 48 years after strabismus surgery. J Pediatr Ophthalmol Strabismus 2005; 42:180-2. [PMID: 15977872 DOI: 10.3928/01913913-20050501-07] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We present a 52-year-old woman who was diagnosed with surgically induced necrotizing scleritis 48 years after strabismus surgery. This case demonstrates the importance of a high index of suspicion for this sight-threatening condition, even many years after strabismus surgery.
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Affiliation(s)
- Tze Lai
- Department of Ophthalmology, Royal Adelaide Hospital, University of Adelaide, South Australia
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