Tectonic corneal lamellar grafting for severe scleral melting after pterygium surgery

Abstract

Purpose To describe the technique and review the indications and success of tectonic corneal lamellar grafting for the management of severe scleral melts after pterygium surgery. Design Retrospective, noncomparative, interventional case series. Participants Twenty cases of severe scleral necrosis after pterygium surgery (1993–1999). Intervention Tectonic corneal lamellar grafting. Surgery involved (1) removal of all devitalized or infected scleral tissue surrounding the melt; (2) use of lamellar or full-thickness donor corneal tissue, fashioned to fit the scleral defect exactly or a 0.25-mm diameter larger; and (3) placement of a pedicled or free conjunctival flap over the corneal lamellar graft. Main outcome measures Eradication of progressive scleral necrosis, preservation of globe integrity, eradication of infection, and preoperative and postoperative visual acuity. Results Sixteen (80%) of 20 cases developed severe scleral necrosis that required tectonic surgery after bare sclera pterygium excision with mitomycin C or β-irradiation. Surgery was also therapeutic to eradicate progressive infection in 6 cases of infective scleritis that did not respond to maximal medical treatment. Scleral melting presented 1 month to 20 years after initial pterygium surgery in healthy, immune-competent adults. Therapeutic and tectonic success was achieved in 19 cases (95%); in 1 case, recurrence of fusarium fungal infection led to severe graft necrosis and intraocular spread. Among the cases of infectious scleritis, three eyes required repeat lamellar grafting to successfully eradicate infection. Conclusions Tectonic and therapeutic lamellar keratoplasty, combined with aggressive antibiotic therapy, preserved globe integrity and eradicated infection in cases of severe scleral melting after pterygium surgery.