Early surgical debridement in the management of infectious scleritis after pterygium excision

Abstract

PurposeThe purpose of this study was to report outcomes of infectious scleritis after pterygium surgery, managed with antibiotic therapies and early scleral debridement.MethodsRetrospective chart review of 13 consecutive cases of infectious scleritis after pterygium excision between 1999 and 2009 was conducted. Collected data included prior medical and surgical history, latency period between pterygium surgery and presentation of infectious scleritis, culture and histopathologic findings, antibiotic regimen, length of hospital stay, visual acuity before and after treatment, and complications.ResultsMedian follow-up was at 14 months. Twelve patients underwent prompt surgical debridement after infectious scleritis diagnosis (median, 2.5 days). Debridement was delayed in one patient. Median hospital stay was 3 days. Best-corrected visual acuity improved in ten patients, remained stable in one patient, and decreased in two patients following treatment. Complications included scleral thinning requiring scleral patch graft (1/13), glaucoma (3/13), and progression to phthisis bulbi (1/13). No patients required enucleation.ConclusionsIn contrast to the generally poor outcomes in the literature, early surgical debridement of pterygium-associated infectious scleritis appears to offer improved prognosis.

Treatment and management of scleral disorders

“…32,58, 83,114,148 These exogenous infections may require combined medical and surgical management because of their more destructive and suppurative nature and poor antibiotic penetration. 22,59,154 Although a rare complication, pterygium excision is the most common surgical procedure associated with infectious scleritis, followed by scleral buckle surgery. Pterygium surgery and scleral buckle surgery represented 75% of reported postoperative cases of infectious scleral necrosis in a recent review of 320 cases.…”

“…74,91,145 In cases of SINS, early surgical intervention correlates with better postoperative best corrected visual acuity (BCVA), complication rates, and globe preservation rates. 154 If tectonic support is required, concomitant use of immunosuppressives are generally required in order to increase the chance of patch graft survival. It is not unusual to experience melting of the patch in eyes with necrotizing scleritis.…”

Clinical characteristics and visual outcomes in infectious scleritis: a review

“…Most studies advocate the avoidance of bare sclera techniques that leave the ocular surface vulnerable to infection. However, in one study by Tittler et al the use of amniotic membrane over an area of debridement was discouraged, suggesting that it provides maximum exposure for topical antibiotics and prevents the incubated microbes from staying at the site, with adequate re-epithelialization occurring shortly after debridement 41. If a bare sclera technique is chosen, close follow-up should be undertaken with examination for scleral ischemia, the first sign of which should prompt conjunctival autografting or other scleral reinforcement 21…”

“…Cryotherapy, lamellar or penetrating corneoscleral grafts, or removal of hardware in addition to intensive antibiotics improves overall outcomes in patients 2,43. Early and repetitive surgical debride-ment is heavily advocated in multiple studies 1,13,22,41,42. Tittler et al showed a 100% globe preservation rate, best corrected vision of 20/120 to 20/400, fewer complications, and shorter hospital stays with prompt surgical debridement at diagnosis (within 2.5 days) 41.…”

Pharmacotherapy of scleritis: current paradigms and future directions

“…The infecting organisms include bacteria, viruses, parasites, or fungi. Most infectious scleritis is classically associated with antecedent trauma, surgical manipulation, such as pterygium excision 10, 11 , cataract extraction 12 , strabismus surgery 13 , or vitrectomy. 14 Scleral buckling is also a risk factor for the development of infectious scleritis.…”