Necrotizing scleritis following pterygium excision

Report
Use of Autologous Fascia Lata in Management
of Necrotizing Scleritis following Bare Sclera
Pterygium Excision
Hatem Kobtan MD FRCS (Ed) (Glasg) Dina koptan MSC
Cairo University
The Authors have no financial disclosure
Ocular History and Examination
•
•
•
55
year
old
male
presented
with scleral
thinning (OS) one week
following
uneventful
primary
pterygium
excision
using
bare
sclera technique.
Penetrating keratoplasty
+ ECCE
&
PCIOL
implantaton
1
month
earlier.
The
sclera bed
is
markedly
thinned,
avascular
with blue
coloration
of
the
underlying uvea.
Necrotizing scleritis
Kobtan
ASCRS 2010
Investigations
•
•
•
•
•
•
•
•
•
A swab with culture and senstivity was taken to exclude
microbial infections and a systemic work up to detect underlying
connective tissue disorder :
CBC, ESR, urea and electrolytes, liver function test.
CH50 (total haemolytic complement).
C reactive protein (CRP).
Rheumatoid factor.
Antinuclear antibody (ANA).
Anti-double stranded DNA.
Chest radiography.
The results of the above tests came out as negative
Necrotizing scleritis
Kobtan
ASCRS 2010
Intra operative
• Autologous fascia lata
was considered as an
option to cover the area
of scleral melt.
• The sutured fascia was
covered with a rotational
conjunctival flap.
Intra-operative appearance of the harvested fascia lata
Necrotizing scleritis
Kobtan
ASCRS 2010
Immediate post operative
Necrotizing scleritis
Kobtan
ASCRS 2010
One week post operative
• One week later the fascia
started to retract near the
limbus
revealing
the
underlying progression of
scleral melt (yellow arrow).
• Systemic steroids 80 mg/day
and Azathioprine 150 mg/day
were therefore added for next
9 month.
Necrotizing scleritis
Kobtan
ASCRS 2010
36 Week post operative
•The fascia lata has been
incorporated into underlying
scleral bed with adequate
vascularization
of
the
overlying conjunctiva.
•No
recurrence
of the
necrotizing
scleritis
was
observed
for
9 month
postoperative.
•The response to immune
suppression supports
a
primary
autoimmune
etiology.
Necrotizing scleritis
Kobtan
ASCRS 2010
Etiology of SINS
• Surgically
induced necrotizing scleritis (SINS) has been reported to
occur after cataract extraction, trabeculectomy, squint surgery and
surgery for retinal detachment.
•
Scleral melting and necrosis is also a well reported complication
following
pterygium surgery with the use of adjunctive irradiation or
treatment with MMC.
 Systemic immunosuppressives have been found to be successful in the
treatment of SINS.
 Vasculitis with fibrinoid necrosis and neutrophil invasion of the vessel
wall was present in the scleral and the conjunctival specimens of our
patient.
Necrotizing scleritis
Kobtan
ASCRS 2010
Immunopathology of SINS
• Autoimmunity
This derives from the fact that associated clinical or serological markers
for connective tissue disorders are present in 62% of cases.
• Hypersenstivity
Immune complexes have been found in & around episcleral vessel walls.
Necrotizing scleritis
Kobtan
ASCRS 2010
• The term "bare sclera" is used to describe
the surgical
denudement of episcleral tissue and vessels which occurs when
pterygium tissue is aggressively removed, leaving a bare and
avascular scleral bed.
• Excessive cautery promotes this avascular state causing
localized ischaemia at the surgical site resulting from
disruption of
episcleral vasculature.
• Bare
sclera technique is certainly not very efficacious
and may not be quite as safe as we had previously thought.
References
• Zainah Alsagoff, Donald T H Tan, S-P Chee. Necrotising
scleritis after bare sclera excision of pterygium. Br J
Ophthalmol 2000;84:1050-1052
• M R Vagefi, D A Hollander, G D Seitzman and T P Margolis.
Bilateral surgically induced necrotising scleritis with secondary
superinfection.
Br
J
Ophthalmol
2005;89:124-125
• Young AL, Wong SM, Leung AT, Leung GY, Cheng LL,
Lam DS, Successful treatment of surgically induced
necrotizing scleritis with tacrolimus.Clin Experiment
Ophthalmol. 2005 Feb;33(1):98-9.

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