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E. H. Tittler, P. Nguyen, J. C. Song, S. C. Yiu; Surgical Debridement of Infectious Scleritis After Pterygium Excision. Invest. Ophthalmol. Vis. Sci. 2009;50(13):2695.
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Necrotizing scleritis (NS), related to pterygium excision and mitomycin C application, is an aggressive soft tissue infection with high morbidity rate. These patients have poor outcomes and many complications, e.g. uveitis, ulcerative keratitis, cataract, glaucoma, retinal detachment, or evisceration. Recently, emergent surgical debridement has been advocated over conservative management to improve outcome in post-pterygium excision NS and, still, outcomes have been poor.1 While we agree that the most significant determinants of clinical outcome are early recognition, expeditious wide-margin debridement, and broad-spectrum antibiotic coverage, this study demonstrates improved outcomes, providing supporting data for the expeditious surgical approach.
Retrospective chart review of nine consecutive patients from 1999 to 2008 with a history of a pterygium excision who developed NS and received surgical debridement. Patient data included age at presentation, time lapse between diagnosis and debridement, microbiology culture results, visual acuity before and after debridement, post-debridement patient complaints, and post-debridement eye pathologies.
Average age at presentation was 71.1 years (range = 53-92). Average time lapse between diagnosis and debridement was 12.2 days (s.d. = 14.4, range = 1-46). Five of the nine patients had positive bacterial cultures, four with Pseudomonas aerugenosa and one with Eikenella corrodens. Average visual acuity before debridement was counting fingers and after debridement was 20/60. Most common post-debridement complaints were itching (n = 4), pain (n = 4), and blurred vision (n = 3). Most common eye pathologies that developed post-debridement were cataract (n = 2) and increased intraocular pressure (n = 2). Other pathologies included scleral thinning requiring a scleral patch graft, entropion, and posterior synechiae.
Literature review suggests that early surgical debridement confers improved prognosis compared to initial conservative management. Overall prognosis remains poor with many complications, necessitating repeat surgeries and prolonged treatments. Our study presents nine consecutive patients with post-pterygium excision NS with improved visual acuity and symptomatology following aggressive surgical debridement. All eyes were salvaged. We emphasize the benefits of expeditious scleral debridement and encourage a lower threshold for surgical intervention in patients with refractory surgically induced necrotizing scleritis.1Huang FC, Huang SP, Tseng SH. Management of infectious scleritis after pterygium excision. Cornea. 2000;19:34-39.
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