Imaging Studies in a Case of Infectious Scleritis After Pterygium Excision

Case Report

Imaging Studies in a Case of Infectious Scleritis after Pterygium Excision

Pho Nguyen, Samuel C. Yiu1

ABSTRACT Access this article online Website: A 44-year-old woman presented with a painful red eye for 2 weeks. Ultrasound biomicroscopy www.meajo.org and optical coherence tomography were instrumental in the diagnosis and management of DOI: this case of infectious scleritis associated with previous pterygium excision complicated by 10.4103/0974-9233.97953 choroidal and retinal detachments. Quick Response Code:

Key words: Infectious Scleritis, Optical Coherence Tomography, Optical Coherence Tomography, Pterygium, Surgical Debridement, Ultrasound Biomicroscopy

INTRODUCTION shallow, with 1+ cells and 1 clock hour of posterior synechiae. The anterior vitreous and funduscopic examination was normal. nfectious scleritis associated with ocular surgery is a The left eye was remarkable only for trace anterior stromal scar Irare entity, which often results in potentially destructive in the nasal region of the cornea adjacent to a conjunctival scar. complications with loss of vision or the globe.1-9 Herein, we Further query revealed a history of pterygium excision 15 years describe the use of immersion ultrasound biomicroscopy (UBM) prior to presentation in Mexico. and spectral-domain optical coherence tomography (OCT) studies of postoperative necrotizing scleritis complicated by The patient was instructed to begin empiric topical antibiotics choroidal and retinal detachments. (fortified vancomycin 50 mg/ml, fortified tobramycin 14 mg/ml, and moxifloxacin 0.05% Q1H) with the diagnosis of necrotizing CASE REPORT sclerokeratitis associated with pterygium excision in the right eye. The culture was positive for Pseudomonas aeruginosa. On A 44-year-old Hispanic female, previously healthy, was referred day 3 after presentation, fundus examination was suggestive of for autoimmune scleritis of the right eye, refractory to two- double retinal and choroidal detachment. week course of oral prednisone, indomethacin, hydrocodone/ acetaminophen, as well as, prednisolone acetate 1% and Immersion UBM with a 35-MHz probe of the right eye homatropine 5% eye drops. Initial visual acuity was 20/200, showed a shallow anterior chamber with anterior rotation right eye, and 20/40, left eye; intraocular pressure was normal of the ciliary body and elimination of the ciliary sulcus in all in both eyes. Slitlamp biomicroscopy revealed mild discharge, quadrants. There was 360° annular choroidal thickening that engorged episcleral and scleral vessels, and a nummular plaque was lacey in appearance without any loculated serous fluid of avascular sclera with necrosis and adjacent corneal infiltration [Figures 2a and b]. Contact B-scan ultrasonography with a in the nasal quadrant [Figure 1]. The anterior chamber was 10-MHz probe showed a relatively clear vitreous cavity with an

Doheny Eye Institute, Los Angeles, California, 1The Wilmer Eye Institute, Baltimore, Maryland, USA, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. Corresponding Author: Dr. Samuel C. Yiu, The Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, MD, 21287 USA. E-mail: [email protected]

Middle East African Journal of Ophthalmology, Volume 19, Number 3, July - September 2012 337 Nguyen and Yiu: Advanced Imaging of Infectious Scleritis elevated peripheral choroidal detachment, nasally and inferiorly detachment. At week 3, the nummular necrosis ceased with new [Figures 2c and d]. There was a mobile serous retinal detachment vascular growth and re-epithelialization [Figure 3a]; and visual in the peripapillary region, with macular involvement. No acuity improved to 20/60 with resolution of subretinal fluid on definite echographic T-sign was present; and retinal tear or OCT [Figure 3b]. mass was also not observed. Spectral-domain OCT confirmed detachment of the macula [Figure 2e]. Small vitreous opacities DISCUSSION and multiple precipitates in the subretinal space were also evident. Etiologies of scleral inflammation include immune-mediated, infectious, tumors, lymphoma, and drug-induced. Regarded The patient’s clinical condition stabilized with diminution of as a rare complication following pterygium excision, infectious pain and scleral necrosis. Repeat B-scan 2 weeks after initial scleritis may occur within days to as late as two to four decades presentation showed complete resolution of the peripheral postoperatively.1-3 Adjunctive therapies, e.g. β-irradiation, choroidal detachment with persistent serous macula-off retinal mitomycin C, or excessive cauterization, have been implicated in the pathogenesis of infectious scleritis after pterygium excision. Early diagnosis is essential and delayed management leads to prolonged hospitalization, repeat debridement, poor visual outcome, and loss of globe.2-9 The clinical course of this patient with delayed diagnosis and initial treatment with oral prednisone was complicated by choroidal and retinal detachment. Early surgical intervention has been advocated to decrease bacterial load and improve antibiotic penetration.2,3,6 Our own series10 also suggests that early debridement is associated with improved visual prognosis and globe preservation. This is especially important as infectious and necrotizing scleritis is much more likely to be vision threatening compared to other causes of scleritis.

The present case highlights the utility of UBM and OCT for the evaluation and management of infectious scleritis. Along with the Figure 1: External photography showing conjunctival chemosis, engorged episcleral and scleral vessels, nummular scleral area of avascularity and necrosis, and small clinical history of pterygium excision, these imaging modalities perilimbal corneal infiltration adjacent to scleral lesion eliminated other causes of scleral inflammation and retinal detachment and aided in evaluating disease progression and managing the clinical course. To the best of our knowledge, this is the first report of ultrasonographic findings of anteriorly rotated

a b

c d

e Figure 2: Advanced imaging studies of complications of infectious scleritis, (a) 35-MHz immersion ultrasound biomicroscopy demonstrating shallow anterior chamber, thickened and anteriorly rotated ciliary body (arrow), and elimination of the ciliary sulcus, (b) Thickened episcleral, scleral, and choroidal tissues are evident in the magnified view, (c) 10 MHz B-scan utrasonography showing double retinal b and choroidal detachment, longitudinal-12 (L-12) view and (d) longitudinal-macular Figure 3: Resolution of infectious scleritis lesion after a 3-week course of fortified (L-mac) view. Spectral domain optical coherence tomography showing vitreous tobramycin and fortified vancomycin, and moxifloxacin 0.05%, (a) External clumps (dotted arrows and circles), subretinal fluid, and subretinal precipitates photograph, (b) Optical coherence tomography image showing resolution of serous (solid arrow) retinal detachment

338 Middle East African Journal of Ophthalmology, Volume 19, Number 3, July - September 2012 Nguyen and Yiu: Advanced Imaging of Infectious Scleritis ciliary body and double choroidal and retinal detachment, as Intrascleral dissemination of infectious scleritis following well as OCT findings of cells in the vitreous cavity and possible pterygium excision. Br J Ophthalmol 1998;82:29-34. 6. Huang FC, Huang SP, Tseng SH. Management of infectious lipofuscin-laden macrophages in the subretinal space, in this scleritis after pterygium excision. Cornea 2000;19:34-9. disease entity. Both UBM and OCT are effective imaging 7. Huang SC, Lai HC, Lai IC. The treatment of Pseudomonas modalities that may be used as adjuncts to the diagnosis and keratoscleritis after pterygium excision. Cornea 1999;18:608-11. management of complex cases of infectious scleritis. 8. Tsai YY, Lin JM, Shy JD. Acute scleral thinning after pterygium excision with intraoperative mitomycin C: A case report of scleral dellen after bare sclera technique and review of the REFERENCES literature. Cornea 2002;21:227-9. 9. Riono WP, Hidayat AA, Rao NA. Scleritis: A clinicopathologic 1. Jabs DA, Mudun A, Dunn JP, Marsh MJ. Episcleritis and study of 55 cases. Ophthalmology 1999;106:1328-33. scleritis: Clinical features and treatment results. Am J 10. Tittler EH, Nguyen P, Rue KS, Vasconcelos-Santos DV, Song JC, Ophthalmol 2000;130:469-76. Irvine JA, et al. Early surgical debridement in the management 2. Jain V, Garg P, Sharma S. Microbial scleritis-experience from of infectious scleritis after pterygium excision. J Ophthalmic a developing country. Eye (Lond) 2009;23:255-61. Inflamm Infect 2012;2:81-7. 3. Reynolds MG, Alfonso E. Treatment of infectious scleritis and keratoscleritis. Am J Ophthalmol 1991;112:543-7. 4. Lin CP, Shih MH, Tsai MC. Clinical experiences of infectious scleral ulceration: A complication of pterygium operation. Br Cite this article as: Nguyen P, Yiu SC. Imaging studies in a case of infectious scleritis after pterygium excision. Middle East Afr J Ophthalmol 2012;19:337-9. J Ophthalmol 1997;81:980-3. 5. Hsiao CH, Chen JJ, Huang SC, Ma HK, Chen PY, Tsai RJ. Source of Support: Nil, Conflict of Interest: None declared.

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