Infectious Scleritis after Retinal Surgery

doi:10.1016/j.ajo.2007.11.024

American Journal of Ophthalmology

Volume 145, Issue 4, April 2008, Pages 695-699

https://doi.org/10.1016/j.ajo.2007.11.024 Get rights and content

Purpose

To report a series of patients in whom infectious scleritis developed after vitreoretinal surgery.

Design

Interventional case series of four patients.

Methods

Medical records of patients at a single institution in whom infectious scleritis developed after vitreoretinal surgery were reviewed.

Results

In three patients, infectious scleritis developed after 20-gauge pars plana vitrectomy, and in one patient, infectious scleritis developed after a scleral buckling procedure. Three cases were had positive culture results; the identified organisms were Pseudomonas aeruginosa in two cases and methicillin-resistant Staphylococcus aureus in one. The fourth patient did not have culture results but responded rapidly to empiric treatment with moxifloxacin. In one patient, surgically induced necrotizing scleritis subsequently developed.

Conclusions

Although infectious scleritis is an uncommon complication after vitreoretinal surgery, it should be a considered cause in patients with persistent postoperative pain and inflammation.

Section snippets

Methods

The charts of patients in whom infectious scleritis developed after vitreoretinal surgery at a single institution were reviewed. Four eyes of four patients were identified. The preoperative histories, surgical procedures, postoperative course, and intervention for complications were recorded.

Case 1

A 65-year-old woman with decreasing visual acuity (VA) measuring 20/80 was diagnosed with an idiopathic epiretinal membrane in the left eye. She underwent an uneventful 20-gauge pars plana vitrectomy with membrane peeling. The sclerotomies were closed with 7-0 Vicryl sutures (Ethicon, Somerville, New Jersey, USA). One week after surgery, she reported severe pain and decreased vision. Examination disclosed hand movement vision, intraocular pressure (IOP) of 38 mm Hg, and a hypopyon. No

Discussion

Infectious scleritis after ocular surgery has been reported frequently in pterygium surgery,1, 2, 5 and also in cataract surgery, corneal grafting, suture removal, trabeculectomy, and strabismus surgery.3, 4 Confirmed infectious scleritis after vitreoretinal surgeries such as scleral buckling surgery⁶ and vitrectomy⁷ have been reported only twice previously, to our knowledge. Lyne and Lloyd-Jones reported a case of coagulase-negative Staphylococcus albus five months after a scleral buckling

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Since the first report of corneal ulcers caused by Mycobacterium fortuitum in the 1960s [29], atypical mycobacteria have been increasingly acknowledged as important causes of ocular infections [10,30]. In addition to infectious keratitis, the most common ocular infection, atypical mycobacteria have also been reported to cause scleral abscesses [31–33], infections of the lacrimal drainage system [34], orbital cellulitis [35], and endophthalmitis [36–38]. The rates of atypical mycobacterial keratitis (AMK) differ with different geographical locations.
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Also, it is effective against aminoglycoside-resistant and sensitive P. aeruginosa.51 Other fluoroquinolones, such as moxifloxacin 400 mg and levofloxacin 500 mg, are also a good alternative in these cases.29,114 P. aeruginosa typically responds well to systemic amikacin (15 mg/kg/day IM or IV) and ceftazidime (30-50 mg/kg/day IV); piperacillin is another excellent alternative.51,86
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.
Tectonic corneal lamellar grafting for surgically-induced necrotizing scleritis after strabismus surgery: Case report & literature review
2018, American Journal of Ophthalmology Case Reports
To report the first case of infectious surgically-induced necrotizing scleritis following strabismus surgery which was treated successfully with a tectonic corneal graft.
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.
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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Nontuberculous mycobacteria (NTM) or atypical mycobacteria, are non-motile, aerobic, non-spore-forming bacilli, which have been reported in a variety of ophthalmic infections, such as keratitis, canaliculitis, uveitis, dacryocystitis, orbital cellulitis, and endophthalmitis [1–4].
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This has been associated with post-traumatic or post-surgical processes in several recent studies.4,5 Cases following pterygium surgery are most frequently reported, but infectious scleritis has also been described after excisions of conjunctival neoplasms, as well as cataract, vitreoretinal, and glaucoma surgeries.3,4,6–8 The most feared complication of intravitreal injections is endophthalmitis.
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Original articleInfectious Scleritis after Retinal Surgery

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Case 1

Discussion

Am J Ophthalmol

Ophthalmology

Ophthalmology

Am J Ophthalmol

Intrascleral dissemination of infectious scleritis following pterygium excision

Br J Ophthalmol

Necrotizing scleritis after ocular surgeryA clinicopathologic study

Ophthalmology

Original article
Infectious Scleritis after Retinal Surgery