Scleral Ulceration Research Articles

Application of Decellularized Porcine Sclera in Repairing Corneal Perforations and Lamellar Injuries.

Scleras are mainly used for the treatment of glaucoma, eyelid damage, and scleral ulcers. Given that the sclera and cornea collectively constitute the complete external structure of the eyeball and both have the same tissue and cell origin, we attempted to identify scleral materials to treat lamellar and penetrating corneal injuries. Based on research in our center, antigenic components in decellularized porcine sclera (DPS) were removed using a simplified decellularization method, leaving the collagen structure and active components undamaged. DPS preserved the mechanical properties and did not significantly inhibit the proliferation and replication of human corneal epithelial cells. In vivo, the graft epithelium healed well after lamellar and penetrating scleral grafting, and the graft thickness did not change evidently. DPS can resist suture traction during scleral transplantation and maintain anterior chamber stability until day 28 post-operatively, especially in penetrating repairs. No obvious immune rejection of lamellar or penetrating scleral grafts was found 28 days after DPS transplantation. This study shows that DPS could be used as an alternative material for the emergency repair of corneal perforations and lamellar injuries, representing another application of sclera.

Monitoring therapy in anterior necrotizing scleritis with inflammation with anterior segment optical coherence tomography.

Early diagnosis and initiation of immunosuppression can prevent the necessity of surgical intervention in necrotizing scleritis with inflammation and lowers the risk of perforation and loss of vision. However, clinical signs for early diagnosis and methods for monitoring response to immunosuppressive therapy are missing. Here, we present a case of necrotizing scleritis with inflammation where avascular plaques precede scleral defects. We use slit lamp imaging and anterior segment optical coherence tomography to evaluate evolution lesions depth and impact on scleral structure. The patient presented 5 months after detection of avascular plaques with a new scleral ulcer of the left eye. After 3-day-administration of i.v. corticosteroids anterior segment optical coherence tomography showed progressive scleral thickening. The patient was therefore spared surgical intervention and discharged resulting in complete remission under decreasing doses of oral corticosteroids. Avascular plaques can precede necrotizing scleritis with inflammation by several months and may therefore qualify as early clinical signs. Anterior segment optical coherence tomography enables objective evaluation of scleral structure for making rational decisions about surgical intervention.

Evaluation of the recurrence rate and complications for pterygium treated with limbal conjunctival autograft

AIM: To evaluate the safety and efficacy of limbal conjunctival autograft transplantation for treating primary pterygium over a period of 3y. METHODS: Prospective observational consecutive case series. In this study, 264 eyes of 264 patients (142 males and 122 females) with nasal primary pterygium were treated using the technique of limbal conjunctival autograft. The mean ages of the patients were 54.22±15.24y. After excision of the pterygium patients were followed up on 1, 3, 7d and at 1, 3, 6, 9, 12, and 36mo. Recurrence of pterygium, complications, operation time and corneal epithelialization time were evaluated. RESULTS: The average surgery time was 25.7±2.6min. With a minimum 3-year of follow-up, postoperative corneal epithelialization was completed in 3.85±0.72d. Complications were observed in 14 cases. Vision-threating complications such as iritis, scleral thinning symblepharon or ulceration were not detected in the study. Five eyes with graft edema, 3 eyes with granuloma formation and 6 cases with a subconjunctival hematoma in the nasal conjunctiva. By the end of 3-year follow-up, recurrence was detected in 11 cases. The recurrence rate was 4.17%, and the onset of recurrence was 3mo, the average recurrence time was 8mo. CONCLUSION: There were no severe complications and few recurrences when limbal conjunctival autograft transplantation was performed after long-term follow-up, we suggest that limbal conjunctival autograft transplantation is a safe and effective technique in primary pterygium. We also recommend that 12-month follow-up is optimal on primary pterygium surgery.

An Unusual Case of Surma (Eye Cosmetic) Induced Conjunctival and Scleral Ulceration

An Unusual Case of Surma (Eye Cosmetic) Induced Conjunctival and Scleral Ulceration

Streptococcus pneumoniae endophthalmitis: clinical settings, antibiotic susceptibility, and visual outcomes

Streptococcus pneumoniae endophthalmitis is clinically more severe, more difficult to treat, and carry a higher risk of vision loss, evisceration, or enucleation. This study is to investigate the clinical settings, antibiotic susceptibility, and visual outcomes of S. pneumoniae endophthalmitis at a tertiary referral center in Taiwan. S. pneumoniae endophthalmitis was diagnosed in 38 eyes of 38 patients. The main clinical features were postcataract endophthalmitis (n = 13, 34%) and endophthalmitis associated with corneal ulcer (n = 12, 32%), trauma (n = 6, 16%), endogenous etiology (n = 4, 11%), trabeculectomy (n = 2, 5%), and pterygium excision-related scleral ulcer (n = 1, 3%). Presenting visual acuity ranged from counting fingers to no light perception. Pars plana vitrectomy with intravitreal antibiotics was performed in 17 eyes (39%) in primary or secondary treatments. S. pneumoniae isolates were susceptible to vancomycin (38/38, 100%), penicillin (37/38, 97%), ceftriaxone (37/38, 97%), cefuroxime (12/15, 80%), levofloxacin (13/15 ,87%), and moxifloxacin (15/17, 88%). Final visual acuity was better than 20/400 in 3 of 38 eyes (8%), 5/200 to hand motions in 3 eyes (8%), and light perception to no light perception in 32 eyes (84%). Ten eyes (26%) underwent evisceration or enucleation. Although S. pneumoniae isolates were susceptible to vancomycin, S. pneumoniae endophthalmitis had a very poor visual prognosis.

Current clinical application of sclera and amniotic membrane for ocular tissue bio-replacement.

To report the current clinical applications and trends of scleral and amniotic membrane use in ophthalmology. Review of annual reports from the Catalan Transplant Organization (OCATT), on scleral patch and amniotic membrane eye indications in Catalonia region (Spain) over a 6-year period from 2013 to 2018. A total of 874 scleral and 1665 amniotic membranes patches were implanted, from January 2013 to December 2018. The most frequent indication over the 6-year period for scleral patch was glaucoma surgery (77.5%), eyelid reconstruction (5.2%) and corneal or scleral ulcer (5%). Regarding amniotic membrane, corneal ulcer (26.9%), conjunctival reconstruction (23.8%) and corneal epithelial defect (22.7%) were the most common indications. During the study period, an increasing trend was found on sclera patches for eyelid reconstruction (p = 0.0032) and amniotic membrane for inflammation management (p = 0.0198). Glaucoma surgery and corneal ulcers have represented the top indications for scleral patch and amniotic membrane use, over the period, respectively. A significant trend has also been found towards eyelid reconstruction using scleral patches and amniotic membrane for anterior segment inflammation management. This evolving scenario in tissue use for ocular surgery has to be taken into consideration, especially regarding eye banks facing current and futures changes in tissue preservation, storage and indications.

Infectious scleritis in Taiwan-a 10-year review in a tertiary-care hospital.

The aim of this study was to describe the clinical features of infectious scleritis with distinct inciting events and to analyze the factors associated with poor visual outcome. We retrospectively reviewed the predisposing factors, clinical findings, isolated organisms, complications, and outcomes of patients with infectious scleritis examined between January 2003 and December 2012 at the Chang Gung Memorial Hospital, Taiwan. Forty-five (94%) of 48 patients with infectious scleritis had preceding inciting factors. Prior ocular surgery (40 eyes, 83%), especially pterygium excision (27 eyes, 57%), accounted for the majority of cases; prior accidental injury was found in 5 eyes (10%). The trauma group had a significantly shorter latency and duration of symptoms before diagnosis when compared with the surgery group. Pseudomonas aeruginosa (22 eyes, 46%) was the most commonly identified pathogen, and fungus was detected in 7 eyes (15%). Fungal infections had a longer symptom duration and smaller scleral ulcers at presentations than bacterial infections did. All patients were administered antimicrobials, and early surgical debridement (median 3 days) was performed in 38 eyes (79%). Three eyes (6%) required eyeball removal, and 10 patients (21%) had a posttreatment vision >20/200. With univariate analysis, the identified factors that were significantly associated with poor visual outcomes were visual acuity at presentation worse than 20/200 (P = 0.01), a long duration of hospitalization (P = 0.02), and eyes complicated by scleral thinning (P = 0.034). Infectious scleritis associated with distinct inciting factors or different offending organisms can display divergent characteristics. Intensive antimicrobial treatment and early surgical debridement can salvage eyes.

Scleral Necrosis Secondary to Nonabsorbable Suture Following Ptosis Surgery

We report a unique case of persistent scleral ulceration in a 68-year-old woman who developed eye redness, pain, and photophobia 2 days following external levator advancement with nonabsorbable suture. Slit-lamp biomicroscopy revealed an area of scleral ulceration superonasal to the limbus. The patient was treated with 6 months of topical steroids with some improvement in her condition but without complete resolution. An exposed suture or foreign body was never directly visualized; however, a mobile nodule was noted upon palpation of the eyelid. Subsequent surgical eyelid exploration revealed a retained polypropylene suture, which was dissected free and removed. Postoperatively, the area of scleral ulceration resolved completely.

Cryptococcal IRIS in the anterior segment of the eye

Cryptococcal IRIS in the anterior segment of the eye

Ulcera escleral secundaria a quemadura química por pila de reloj y cuerpo extraño retenido en fondo de saco conjuntival inferior: Caso clínico

abstract scleral ulcer secondary to chemical burn caused by watch battery and retained foreign body in conjunctival sac inside. case report introduction: Approximately one-third of childhood blindness is due to trauma, representing the leading cause of visual impairment and monocular blindness in children. case report: the patient is a 2 year old pre-school boy, who presented scleral ulcer in his left eye secondary to chemical burn caused by watch battery. the reason for seeking medical care was difficult healing caused by a mineral foreign body retained in the lower conjunctival sac after the patient came in contact with detergent one month before the pediatric consultation. Discussion: An unusual case of scleral ulcer was reported. So far, no other similar cases have been reported. the diagnosis process and the delay for the removal of the foreign body are emphasized in this serious ophthal-mologic emergency. (Key words: Chemical burn, scleral ulcer, ocular trauma).Rev Chil Pediatr 2012; 83 (6): 582-586

Tratamento da úlcera escleral pós-cirurgia de pterígio e betaterapia por enxerto de esclera autóloga de espessura parcial

OBJETICVE: The authors describes a surgical technique that utilizes autologus delaminated scleral graft for the management of deep scleral ulcers. METHODS: In this technique that were perfomed in 12 eyes of 12 patients, 9 female, 3 male, age from 48 to 82 years, mean age 65.2 years. RESULTS: Occurred good integration of the grafting in all cases without any complications. CONCLUSION: Many techniques have been proposed for the management of scleral ulcers: sclera and dura-mater, autologus derme, auricular cartilage and [...]

The role of radiotherapy in the treatment of pterygium: A review of the literature including more than 6000 treated lesions

Pterygium is a benign conjunctival neoformation usually treated by surgical excision, but recurrences may affect 30% to 89% of cases, so that adjunctive therapies like conjunctival autografting, antimitotic drugs and beta-irradiation (β-irradiation) are often used to improve the rate of local control. Our essay has reviewed relevant studies addressing the role of postoperative irradiation in the treatment of pterygium in the last 30 years through an Internet-based search and hand search in libraries. Sixteen studies on β-irradiation and one on soft X-ray irradiation were accessible. They covered more than 6000 lesions treated by surgical excision and postoperative β-irradiation using strontium-90 ( 90Sr) applicators at doses varying from 10 to 60 Gy/1–6 fractions/1–6 weeks starting within 3 days postoperatively. The rates of local recurrence were in general lower than 15% and major complications such as scleral thinning, ulceration, infections, or radiation-induced cataract were rarely encountered. Early postoperative β-irradiation at a dose of 30 Gy/three fractions/2–3 weeks starting within 24 h from surgical excision is an effective and safe procedure with local control rates comparable to chemotherapeutic agents and conjunctival autografting and superior to simple excision alone.

Iatrogenic Conjunctival Entrapment of Cilium and Scleral Ulceration After Subtenon Steroid Injection

To report the presence of an asymptomatic cilium in the subconjunctival area and an adjacent sterile scleral ulcer, together as a complication of subtenon injection of steroids, and the resolution of the ulcer despite the in situ cilium. Medical management of a 51-year-old man, who was a known case of ankylosing spondylitis, with a 3-mm scleral ulcer located in the inferior palpebral area with one adjacent fully embedded cilium at the probable site of subtenon injection given for suspected acute iridocyclitis. On altering the medication, the ulcer resolved completely. This occurred despite the in situ cilium, which did not act as a nidus for infection or inflammation. The presence of cilia did not adversely affect the outcome of treatment of the adjacent ulcer. Therefore, if there is no exposure of the entrapped cilium through the conjunctiva, as was in this case, conservative management of the ulcer and not trying to remove the cilium seems to be a good alternative as opposed to reports in literature, which warrant its removal in most cases.

Scleral ulceration after vitreoretinal surgery

Scleral ulceration after ocular surgery is a rare but serious complication. Determination of the underlying systemic and local causes is critical for treatment. An unusual case of ischemic scleral ulceration after vitreoretinal surgery in a diabetic patient is reported. Patient was successfully treated with a pedicle conjunctival graft.

Long-Term Results and Prognostic Factors of Fractionated Strontium-90 Eye Applicator for Pterygium

To evaluate the long-term safety, effectiveness, and prognostic factors of fractionated postoperative beta-irradiation. Between 1993 and 2005, 623 patients with 737 pterygium lesions were treated with a strontium-90 eye applicator after surgical excision. The median follow-up period was 60 months (range, 6.7-139.5). Of the 737 lesions, 644 were primary and 93 were recurrences after surgical removal alone. Fractionated radiotherapy (RT) to a total dose of 35 Gy in five to seven fractions was used. A total of 73 local pterygium recurrences (9.9%) were noted. Of the recurrent cases, 80% were noted within 3 years after treatment. The 5- and 10-year probability of local control was 90% and 88%, respectively. The multivariate analysis for all cases demonstrated that gender, age, total radiation dose, recurrent pterygia, and interval between surgery and RT affected the overall local control rate. Late toxicities that might have been associated with strontium-90 RT included scleromalacia (scleral thinning) in nine eyes, adhesion of the eyelids in eight, cataracts in six, and scleral ulcer in five eyes. Fractionated strontium-90 RT to a total dose of approximately 35 Gy in five to seven fractions results in a similar local control rate as higher doses in other series, with an acceptable complication rate.

Clinical efficacy of amniotic membrane transplantation in the treatment of various ocular surface diseases

Purpose To investigate the efficacy of permanent amniotic membrane transplantation (AMT) for the treatment of various ocular surface diseases. Methods The medical records of 62 eyes from 58 patients who had undergone permanent AMT were reviewed. The amniotic patches were grafted for the treatment of neurotrophic ulcers ( n = 15), inflammatory corneal ulcers ( n = 15), scleral ulcers ( n = 11), painful bullous keratopathy ( n = 8) and pterygium as an adjuvant to a conjunctival autograft ( n = 13). Cryo-preserved or freeze-dried amniotic membrane (AM) were used. The overall success rate, the interval to epithelialization, pain-subsiding time, and complications were evaluated. The pain relief and the full epithelialization interval in the bullous keratopathy patients given the cryo-preserved AM were compared with those given the freeze-dried AM. Results The success rate in the patients with neurotrophic ulcer, inflammatory corneal ulcer, scleral ulcer and bullous keratopathy were 93.3%, 66.7%, 92.9% and 100%, respectively. A conjunctival autograft with AMT showed a 100% success rate without recurrence. The time to re-epithelialization was 24.4 ± 24.2, 20.4 ± 5.8, and 16.9 ± 7.0 days in patients with neurotrophic, inflammatory and scleral ulcers, respectively ( p = 0.431). The pain relief interval in the cryo-preserved and freeze-dried AM group was 17.7 and 23.3 days, and the re-epithelialization interval was 29 and 22 days, respectively, which was insignificant. Conclusions AMT has a high success in the treatment of neurotrophic, scleral ulcer, bullous keratopathy and pterygium with a low rate of complications but presented only partial success in the treatment of inflammatory corneal ulcers. The clinical efficacy of AMT was not related to the methods used to preserve the AM.

Clinicopathologic case report: scleral buckle associated nontuberculous mycobacterial scleritis

Nontuberculous mycobacterial (NTM) infections have become increasingly important in ophthalmology, particularly with keratorefractive surgery. We report a case of scleral buckle associated NTM scleritis occurring in a 69-year-old male after silicone sponge explant removal. Purulent scleral ulceration with nodule formation persisted despite topical antimicrobial therapy, buckle removal, and surgical debridement. Eventually, tissue biopsy revealed noncasseating granulomas with acid-fast bacilli that were identified in culture as Mycobacterium chelonae. The infection resolved only after administration of systemic antibiotics. NTM are important pathogens in scleral buckle associated scleritis and should be considered in persistent cases. Surgical therapy remains the cornerstone of therapy, but antimicrobials, particularly newer fourth generation fluoroqunilones, may have an important role in treating scleral buckle associated NTM scleritis.

Surgical Management of Scleral Perforation After Pterygium Excision

Scleral perforation is a rare complication occurring after pterygium excision often leading to scleral ulceration and loss of vision. Our purpose is to evaluate the long-term effectiveness and safety of tenonplasty and amniotic membrane transplantation in the management of scleral perforation after pterygium excision. We performed a retrospective study on patients with scleral perforation after pterygium excision that underwent tenonplasty and amniotic membrane transplantation at Chang Gung Memorial Hospital from 1997 to 1999 and followed up for at least 12 months postoperatively. There were 6 patients, 1 male and 5 females ranging in ages from 46 to 71 years (mean, 63.3). The interval between pterygium excisions to scleral perforation ranged from 3 to 20 years. There were no recurrences during the follow-up period of 12 to 24 months (average, 18.3 months). Tenonplasty and amniotic membrane transplantation appears to be a relatively simple, safe, and effective method for treating scleral perforation after pterygium excision.

Multilayered amniotic membrane transplantation for severe ulceration of the cornea and sclera

PURPOSE: To examine the efficacy of amniotic membrane transplantation in the treatment of deep corneal and scleral ulcers. PATIENTS: A total of 11 patients were recruited for this study: four patients (four eyes) with corneal perforation, five patients (five eyes) with a deep corneal ulcer and descemetocele, and two patients (two eyes) with a scleral ulcer. METHODS: Ulcers were treated by amniotic membrane transplantation. Separate amniotic membranes were transplanted as material to fill the stromal layer (amniotic membrane filling), as a basement membrane (amniotic membrane graft), and as a wound cover (amniotic membrane patch). After surgery, all cases were treated with artificial tears, autologous serum drops, antibiotic eyedrops, topical corticosteroids, and sodium hyaluronate eyedrops. RESULTS: Eight eyes (72.7%) healed with epithelialization in 16.5 ± 8.0 days (range, 7 to 29 days), with five and three eyes showing corneal epithelialization and conjunctival epithelialization, respectively. A persistent epithelial defect was noted in one eye with corneal ulcer after limbal allograft transplantation for a chemical burn and in two eyes with corneal ulcers as a complication of rheumatoid arthritis. CONCLUSION: Multilayered amniotic membrane transplantation may be effective for the treatment of deep ulceration of the cornea and sclera. In some eyes with total corneal limbal dysfunction or autoimmune disorders, amniotic membrane transplantation alone is not effective.

Long-term results of fractionated strontium-90 radiation therapy for pterygia

Purpose: The long-term safety and effectiveness of fractionated strontium-90 radiation therapy (RT) for pterygium were reviewed retrospectively. Methods and Materials: Between 1984 and 1996, 399 patients with 490 pterygia were treated with a strontium-90 eye applicator following surgical removal of the pterygium. The median follow-up period was 61 months (range 2–178). Of the 490 pterygia, 452 were fresh, 17 were recurrences after surgical removal alone, and 21 were recurrences after surgical removal plus postoperative RT. Fractionated RT of 31–42 Gy/4–5 fractions/22–29 days was given for 95.1% of the pterygia. Results: In total, 58 (11.8%) local recurrences of pterygia were noted. The median time of local recurrences was 10 months, ranging from 2 to 93 months, and 16 recurrences (28%) were noted later than 24 months after treatment. The interval between surgery and the start of RT (1–3 days vs. > 3 days) and recurrent pterygia were significant variables for local control in the multivariate analysis, while total RT dose (7–29 Gy vs. 31–50 Gy) was a marginally significant variable. Late toxicities that may be associated with strontium-90 RT were scleromalacia (scleral thinning) in 4 eyes, adhesion of eyelids in 3 eyes, and scleral ulcer in 2 eyes. Conclusion: Fractionated strontium-90 RT of approximately 40 Gy/4–5 fractions was safe and effective for preventing recurrence of pterygia, when RT was started within 3 days of surgery.