Acute scleral thinning after pterygium excision with intraoperative mitomycin C: a case report of scleral dellen after bare sclera technique and review of the literature
Department of Ophthalmology, China Medical College Hospital, Taichung, Taiwan. Cornea
(Impact Factor: 2.04).
To describe a patient with scleral dellen after pterygium excision with intraoperative mitomycin C.
Case report and MEDLINE review of the medical literature on scleral dellen after bare sclera technique.
A 48-year-old man had a left nasal pterygium excised by the bare sclera technique with intraoperative mitomycin C. Eight days after surgery, the patient noticed a small black spot in the bare sclera area with mild irritation. Slit-lamp examination revealed a focal area of extreme thinning, centered on the nonepithelialized bare sclera, surrounded by edematous conjunctiva. The ciliary body was visible through the thin and dry scleral lesion. After topical lubricant therapy, the scleral lesion appeared normal thickness and white in color 3 days later. Therapy was continued until the sclera epithelialized.
Scleral dellen is an early postoperative complication of bare sclera technique owing to delayed conjunctival wound closure. Hydration of the thinned sclera will rapidly thicken it. However, medical therapy should be continued until the surrounding conjunctiva has flattened and the sclera has epithelialized. Surgical wound closure is an alternative management and may be the way to prevent scleral dellen formation after bare sclera technique. All patients after bare sclera surgery should be followed up until the conjunctival wound has healed. If delayed healing is found, frequent artificial tears, patching, or surgical intervention is necessary.
Available from: Marta Gilardi
- "The surgical excision of the pterygium is a commonly performed procedure with complication rates ranging from 0 to 26% . Scleral dellen have been rarely reported among the complications that might arise after primary pterygium excision with or without adjunctive therapy [6, 7]. The bare scleral technique for pterygium surgery, leaving for some time a denudated sclera, might theoretically favor the onset of corneal dellen, if there are concomitant significant conjunctival edema inhibiting a normal tear distribution over the cornea, and if there is a decreased tear production. "
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ABSTRACT: We describe a patient with corneal and scleral dellen, which occurred after an uneventful pterygium excision without adjunctive therapy and a subsequent febrile episode.
A 43-year-old woman presented with a history of recurrent irritation in her right eye and a diagnosis of pterygium. The pterygium was excised under local anesthesia with the bare scleral technique and without the use of antimetabolites. No complications occurred until 14 days after surgery when corneal and sclera dellen appeared; this was 2 days after a concomitant febrile episode (39°C). Tobramycin and dexamethasone eye drops given after surgery were withdrawn and topical lubricants and antibiotic ointment, in combination with oral L-amino acids, were administered along with eye patching. One week later, the corneal dellen had completely healed and, 4 weeks later, the thinned sclera appeared regularly thick and white in color. Three months after surgery, a small recurrent pterygium was diagnosed, which remained stable without signs of inflammation for additional 18 months.
Corneal and scleral dellen might be a late complication of uneventful pterygium surgery without antimetabolites and a subsequent febrile episode.
Available from: Samuel Yiu
- "Adequate re-epithelialization of the exposed sclera was observed in 12 eyes shortly after debridement. For patient 3, however, a human amniotic membrane graft was deemed appropriate because re-epithelialization did not appear likely to occur due to the severity of scleral thinning . "
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ABSTRACT: The purpose of this study was to report outcomes of infectious scleritis after pterygium surgery, managed with antibiotic therapies and early scleral debridement.
Retrospective 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.
Median 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.
In contrast to the generally poor outcomes in the literature, early surgical debridement of pterygium-associated infectious scleritis appears to offer improved prognosis.
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- "We think that relatively small sample sizes are an important factor causing differences in the reports. Complications as keratitis, corneal endothelial changes, scleral thinning and melting may occur also with intraoperative MMC (Tsai 2002; Safianik et al. 2002; Zhivov et al. 2009; Peponis et al. 2009). We experienced only one serious complication in this group, a corneascleral melting which was managed by lamellar corneal graft. "
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ABSTRACT: To compare the 4-year outcome of primary pterygium excision using intraoperative mitomycin C (MMC) with suturing a free conjunctival autograft (CA).
A total of 115 eyes with nasal primary pterygium of 115 patients were included in the study. After randomization into two groups, the eyes were operated on by a single surgeon (GK). After excision of the pterygium, 56 eyes received 0.04% MMC intraoperatively on the bare sclera for 3 min and 59 eyes received a free CA sutured using 7-0 Vicryl. Postoperative follow-up was 4 years. Main outcome measures were recurrences, re-operations, surgery time, complications, visual acuity and astigmatism. Statistical evaluation was performed with the chi-squared test.
The recurrence rate was 38% in the MMC group and 15% in the CA group (p < 0.05). The re-operation rate of the recurrences was 53% in the MMC group and 29% in the CA group. Average surgery time was 13 minutes (range: 6-22 min) in the MMC group and 26 min (range: 18-32 min) in the CA group (p < 0.01). There was no significant change in best-corrected visual acuity and astigmatism. One major complication occurred in each group. The most frequently observed complication was delayed epithelial healing (40%) and mild scleral thinning (20%) in the MMC group and suture-related inflammation in the CA group (10%).
Pterygium surgery including free autologous conjunctival grafting is associated with fewer recurrences, re-operations and complications than using the bare sclera technique together with single-dose intraoperative MMC.
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