Role of Circumferential Full Thickness Scleral Debridement in Fulminant Infective Ring Scleritis

Abstract

Purpose : To illustrate the role of 360^o surgical debridement in the management of infectious scleritis complicated by the administration of corticosteroids, especially if the infection is extensive and unresponsive to medical therapy.

Methods : We present a series of 4 cases with infectious scleritis, who were exposed to oral steroids during their management resulting in fulminant ring scleritis. Corticosteroids, along with antibiotics [Case 1 & 2], were given in 2 cases as part of routine management. In the third case, the patient developed infectious scleritis at the site of cataract surgery incision with coexisting endophthalmitis. Hence, steroids (oral and topical) were used in conjunction with intraocular antibiotics in its management [Case 3]. The fourth case was misdiagnosed as autoimmune scleritis and initially treated with high dose steroids. In all four cases, initial presentation of focal scleritis had turned into fulminant diffuse anterior necrotizing annular/ring scleritis with multi-focal abscesses. The cases were non-responsive to conservative treatment with anti-microbials and localized surgical debridement. Muscle involvement and posterior extension of scleritis was not present in any of the cases. Therefore, extensive full thickness 360^o annular scleral debridement was performed; corticosteroids (oral and topical) were withdrawn.

Results : All four patients responded well to 360^o annular scleral debridement. One case showed fungal elements, while the other three were non-revealing for any organism. The eyes remained healthy with normal intraocular pressure; no recurrence of scleritis or development of ciliary staphyloma was observed during the last follow-up of 1 year. None of the cases developed corneal involvement or posterior extension of scleritis. The progression of necrotizing scleritis and development of abscesses were annular and limited anteriorly by the limbus and posteriorly by the spiral of Tillaux.

Conclusions : In steroid exposed cases of fulminant infectious scleritis, prompt and extensive surgical debridement can be undertaken to halt progression. Annular debridement created a complete structural disconnection of perilimbal sclera from posterior edge of healthy sclera and did not affect the structural integrity of the eyeball. Hence, circumferential debridement may be considered as an adjunctive intervention in non-responsive/progressive infectious scleritis.

This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.