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To assess the clinical pictures, possible pathogenesis, management, and therapy of patients with infectious scleritis associated with multifocal scleral abscesses following pterygium excision.
The records of patients with infectious scleritis after pterygium excision who developed multifocal scleral abscesses presenting from 1988 to the end of 1995...
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Citations
... Lin et al. [4] reported 30 patients of infectious scleritis in 1997 of which only one had fungal scleritis. In a series by Hsiao et al., [5] only one case had fungal etiology (5%) out of the total 18 cases of infectious scleritis. Aspergillus terreus is a saphrophytic fungus occurring in the soil and can be occasionally pathogenic. ...
A 10-year-old healthy male child presented with pain, redness, and swelling in the left eye of 10 days duration. There was a positive history of trauma. Clinical examination revealed a subconjunctival nodular lesion in the left eye. Surgical exploration under general anesthesia revealed a scleral abscess with an intraocular foreign body lodged in it. Aspergillus terreus growth was obtained on culture. The patient was aggressively treated with anti-fungal medications. Complete resolution was obtained one month following the presentation.
... [33] The most common preceding surgeries reported are scleral buckle, pterygium, vitrectomy, glaucoma valves, intravitreal injections, and cataract surgery. [34][35][36][37][38][39] In an analysis of 18 cases, Kheir et al. observed that 94.4% were preceded by surgery, of which 77.8% had undergone scleral bucking. [33] Another predisposing factor is immunocompromised status. ...
... In other cases, nodules are noted at the surgical sites (pterygium excision and glaucoma implant surgery) and suture abscesses after vitrectomy at the site of scleral port. [36][37][38] Cases with de novo presentation have been reported as isolated scleral nodules. Pisitpayat et al. reported two cases of Mycobacterium haemophilum infection, of which the first was in an immunocompromised individual and presented with multiple pustular lesions. ...
Atypical mycobacteria or non-tuberculous mycobacteria (NTM) are a group of acid-fast bacteria that are pathogenic to different parts of the eye. The organisms can cause a spectrum of ocular infections including keratitis, scleritis, uveitis, endophthalmitis and orbital cellulitis. Trauma, whether surgical or nonsurgical, has the highest correlation with development of this infection. Common surgeries after which these infections have been reported include laser in situ keratomileusis (LASIK) and scleral buckle surgery. The organism is noted to form biofilms with sequestration of the microbe at different inaccessible locations leading to high virulence. Collection of infective ocular material (corneal scraping/necrotic scleral tissue/abscess material/vitreous aspirate, etc.) and laboratory identification of the organism through microbiologic testing are vital for confirming presence of the infection and initiating treatment. In cluster infections, tracing the source of infection in the hospital setting via testing of different in-house samples is equally important to prevent further occurrences. Although the incidence of these infections is low, their presence can cause prolonged disease that may often be resistant to medical therapy alone. In this review, we describe the various types of NTM-ocular infections, their clinical presentation, laboratory diagnosis, management, and outcomes.
... 39,18,40,54 Unifocal or multifocal scleral abscesses appearing as yellowish nodules under the conjunctiva, at times scattered as an arc 3-4 mm from the limbus may be the presenting features in patients with infectious necrotizing scleritis. 56,57 Necrotizing scleritis due to Mycobacterium tuberculosis is relatively rare. Tuberculous scleritis can be caused by either a direct invasion of the sclera of bacilli by hematogenous route, spread from contigious tissues including conjunctiva, cornea, or choroid or by an immune-mediated reaction to circulating mycobacterial antigens. ...
Necrotizing scleritis is the most destructive and vision-threatening form of scleritis. Necrotizing scleritis can occur in systemic autoimmune disorders and systemic vasculitis, as well as following microbial infection. Rheumatoid arthritis and granulomatosis with polyangiitis remain the commonest identifiable systemic diseases associated with necrotising scleritis. Pseudomonas species is the most common organism causing infectious necrotizing scleritis, with surgery the most common risk factor. Necrotizing scleritis has the highest rates of complications and is more prone to secondary glaucoma and cataract than other phenotypes of scleritis. The differentiation between non-infectious and infectious necrotizing scleritis is not always easy but is critical in the management of necrotizing scleritis. Non-infectious necrotizing scleritis requires aggressive treatment with combination immunosuppressive therapy. Infectious scleritis is often recalcitrant and difficult to control, requiring long-term antimicrobial therapy and surgical debridement with drainage and patch grafting due to deep-seated infection and the avascularity of the sclera.
... Various microorganisms previously reported postoperatively after pterygium surgery include Staphylococcus, Pseudomonas aeruginosa, Aspergillus, Mycobacterium fortuitum, and Fusarium species. [2,4,10] Our patient presented with classical manifestations of dendritic ulcer consistent with HSV epithelial keratitis, which had earlier been misinterpreted by the referring surgeon as persistent epithelial defect. The diagnosis in the current case was clinical, and virology laboratory investigation was not available due to logistical reasons; the investigation would otherwise have helped in confirming the presence of HSV. ...
... In this study, two patients had clear histories of mitomycin C and only one had beta irradiation application as the adjuvant therapy for at least 20 years. Pseudomonas aeruginosa scleritis following pterygium surgery with mitomycin C and beta irradiation had been proposed [15][16][17]. Several reasons suggested by Meallet indicated that the application of either mitomycin C or beta irradiation was inclined to compromise conjunctival blood vessels and subconjunctival connective tissues, thus restraining normal conjunctival wounding healing and leaving bare sclera for facile infection [18]. ...
... A unique collagen fiber arrangement of the sclera and a less vascular layer of an outer coat of the eye causes poor penetration of antibiotics for Pseudomonas scleritis treatment. A previous study confirmed the persistence of Pseudomonas pathogen despite laborious antibiotic treatment [17]. However, one eye in our study did not respond to both intensive antibiotic therapy and surgical interventions, which may be related to a strong virulence of Pseudomonas aeruginosa and/or host immune response to the microorganisms. ...
Purpose:
To report three cases of culture-positive Pseudomonas aeruginosa scleritis following pterygium surgery. Patients and Methods. A retrospective study of all patients of Pseudomonas aeruginosa scleritis after pterygium surgery presented from May 2017 to May 2020 was performed. Patient demographics and clinical characteristics included age, gender, time between prior surgery and onset, adjunctive therapy, risk factors, initial visual acuity, final visual acuity, clinical features, medical treatment, and surgical intervention were analyzed.
Results:
Three eyes of three patients with clinical characteristics and laboratory-confirmed Pseudomonas aeruginosa scleritis were identified. Two patients were related with mitomycin C application after pterygium surgery, and only one had beta irradiation. Antibiotic administration and scleral debridement were required in 3 patients. One eye was enucleated. Final visual outcomes of two patients were improved.
Conclusions:
Pseudomonas aeruginosa scleritis after pterygium surgery is a crucial ophthalmic disease. An early diagnosis with a prompt intensive antibiotic treatment in combination with surgical interventions may improve visual outcome.
... Isolated infectious scleritis has a better prognosis than keratoscleritis. It is difficult to manage, as organisms remain in the tightly bound collagen fibres of the scleral layers which are poorly penetrated by the antimicrobials [13]. Surgical debridement aids as a diagnostic tool, therapeutically facilitates the penetration of antibiotics, and debulks the infected scleral tissue. ...
... Systemic and collagen disease work-up should be done to rule out immune etiology. Aggressive and prolonged topical and systemic antibiotics must be instituted in suspected cases of intrascleral dissemination [13]. In absence of perforation of the globe or severe scleral ectasia with uveal exposure during debridement, a scleral graft is not needed [1]. ...
We herein report a case of a young female presenting with multiple nodular scleral abscesses mimicking infective scleritis with exudative retinal detachment. Repeated diagnostic scraping for microbiological and histopathological analysis was inconclusive. The patient's systemic and collagen disease work-up was non-contributory. She was treated with multiple surgical debridement and de-roofing of the abscesses along with antibiotic irrigation. Topical and oral steroid was stopped on worsening of the condition, and the patient was maintained on topical and oral antibiotics. Complete resolution of scleritis and exudative detachment was noted at 1 month follow-up and no recurrence was noted until 6 months.
... The latter may occur post-trauma, ocular surgery, endophthalmitis or from a primary corneal infection [9]. The most common organisms responsible for infectious scleritis are Pseudomonas aeruginosa and fungi [7,10,11]. ...
... Infectious scleritis follows an aggressive course and the clinical outcome is poor in most cases with various series reporting the need for evisceration in severe cases [9,12]. Early initiation of topical and systemic antimicrobial therapy along with surgical debridement can help in salvaging these eyes with improved anatomical success [7,11]. Surgical debridement also aids in the penetration of topical medications while debulking the infected scleral tissue [8]. ...
... Patient 2 presented two months after cataract surgery with a surgical wound infection. Infectious scleritis has been reported after various surgical procedures like pterygium excision, cataract and vitreoretinal surgery [11,17,18]. Patients with a prior history of ocular surgery and then presenting with necrotising scleritis at the site of tissue penetration should be suspected to have infectious scleritis. ...
PurposeTo report the outcomes of a novel technique of scleral debridement in five consecutive cases of relentlessly progressive and fulminant infectious scleritis following corticosteroid exposure.Methods
Five consecutive patients of infectious scleritis with a common history of corticosteroids exposure, resulting from either an initial misdiagnosis of autoimmune scleritis or as anti-inflammatory adjunct to specific antimicrobial therapy. Data collection included presentation details such as photographs, clinical findings, microbiological analysis, treatment details and audit of surgical videos. Cases with undisputed diagnosis of infectious scleritis with microbiological evidence, without corticosteroid use, were excluded from the study.ResultsAfter full-thickness scleral debridement and cessation of corticosteroids, favourable anatomical and visual outcome was observed in all cases; however, two patients required multiple scleral debridements due to progressive scleritis. Scleral patch graft was not used in any case. Microbiology detected infective organisms in two cases, while the remaining revealed negative results. Therefore, specific antimicrobial therapy was initiated in former, whereas empirical broad-spectrum regimen in patients with repeatedly negative microbiological results. No recurrence of scleritis or development of ciliary staphyloma was noted and anatomical integrity was maintained with normal intraocular pressure during follow-up.Conclusion
This study highlights the fulminant and relentlessly progressive clinical course, that infectious scleritis can metamorphose into, despite specific antimicrobial therapy, if inadvertent corticosteroid therapy is administered. Full-thickness debridement without scleral patch graft, could achieve elimination of infectious foci, with favourable long-term anatomical and visual outcome. This technique could offer a potential last-resort approach in such cases where standard therapeutic modalities have not been successful.
... 14 Excessive cauterization and the bare sclera technique can further increase vulnerability to infection. 18 Specifically, the production of collagenases and subsequent enzymatic degradation in response to prolonged exposure of the bare sclera has been proposed as a crucial component in tissue destruction. 19 The use of adjunctive b-irradiation or antimetabolites, such as mitomycin C and thiotepa, can prevent proper re-epithelialization and has been implicated in the pathogenesis of IS. 6 However, pterygium surgery alone can induce infection. ...
... 5,14,16,23 Exposed scleral buckle, exudative retinal detachment, elevated intraocular pressure, sclerochoroidal thickening, and widening of sub-Tenon space may also be consistent with IS. 26,44 In cases involving multifocal scleral abscesses, a black arc-shaped band extending from the initial abscess through satellite lesions due to scleral thinning is indicative of intrascleral dissemination. 18 Furthermore, necrotizing scleritis is frequently associated with infection (93%) and thus should always be considered in the differential diagnosis. 2,5,11 Several reports have described atypical cases featuring a painfree presentation, normal visual acuity, lack of corneal infiltrates, normal intraocular pressure, and absence of anterior chamber reaction. ...
... Although it is highly variable for IS, nonsurgical posttraumatic cases tend to have a much shorter latency (within 1 month) compared with that of postsurgical cases (1 week-36 years). 7,9,14,18 This can be explained by the high probability of more significant ocular surface destruction and greater microbial load in trauma involving organic matter. ...
Infectious scleritis (IS) is a rare and severe ocular disorder responsible for approximately 5%-15% of all scleritis cases. It is often associated with a poor prognosis due to its similar clinical presentation to autoimmune scleritis, resulting in a delayed diagnosis and treatment. Therefore, differentiating between infectious and noninfectious entities is critical. Several details extracted from the patient's history and clinical examination can raise suspicion for infection. The most common predisposing factor is previous ocular surgery, especially pterygium, cataract, and vitreoretinal surgeries. Ocular trauma, poor contact lens hygiene, "eye-whitening" procedures, and subtenon triamcinolone injections have also been implicated. Clinical features of infection include the presence of scleral necrosis, hypopyon, unifocal or multifocal scleral abscesses, and mucopurulent discharge. Thorough diagnostic testing is essential before excluding infection as a possibility. Empiric broad-spectrum topical and systemic antibiotic therapy should be initiated while awaiting laboratory results and adjusted accordingly. Most IS cases require both aggressive medical and surgical treatment, and various studies have reported favorable outcomes with this combination. At this time, there is no consensus on the management of this severe ocular condition, and future studies are needed to establish clear treatment guidelines.
... The latter may occur post-trauma, ocular surgery, endophthalmitis or from a primary corneal infection [9]. The most common organisms responsible for infectious scleritis are Pseudomonas aeruginosa and fungi [7,10,11]. ...
... Infectious scleritis follows an aggressive course and the clinical outcome is poor in most cases with various series reporting the need for evisceration in severe cases [9,12]. Early initiation of topical and systemic antimicrobial therapy along with surgical debridement can help in salvaging these eyes with improved anatomical success [7,11]. Surgical debridement also aids in the penetration of topical medications while debulking the infected scleral tissue [8]. ...
... Patient 2 presented two months after cataract surgery with a surgical wound infection. Infectious scleritis has been reported after various surgical procedures like pterygium excision, cataract and vitreoretinal surgery [11,17,18]. Patients with a prior history of ocular surgery and then presenting with necrotising scleritis at the site of tissue penetration should be suspected to have infectious scleritis. ...
PurposeWe report the outcomes of a novel technique of scleral debridement in five consecutive cases of relentlessly progressive and fulminant infectious scleritis following corticosteroid exposure.Methods
Five consecutive patients of infectious scleritis with a common history of corticosteroids exposure; resulting from either an initial misdiagnosis of autoimmune scleritis or as an adjunct to specific antimicrobial therapy. Data collection included presentation details including photographs, clinical findings, microbiological analysis, treatment details and audit of surgical videos. Cases with undisputed diagnosis of infectious scleritis with microbiological evidence; without corticosteroid use, were excluded from study.ResultsAfter full-thickness scleral debridement and cessation of corticosteroids, favourable anatomical and visual outcome was observed in all cases; however, two patients required multiple scleral debridements due to progressive scleritis. Scleral patch graft was not used in any case. Microbiology detected infective organisms in two cases, while the remaining revealed negative results. Therefore, specific antimicrobial therapy was initiated in former, whereas empirical broad-spectrum regimen in patients with repeatedly negative results. No recurrence of scleritis or development of ciliary staphyloma was noted and anatomical integrity was maintained at normal intraocular pressure during follow-up.Conclusion
This study highlights the fulminant and relentlessly progressive clinical course, that infectious scleritis can metamorphose into, despite specific anti-microbial therapy, if inadvertent corticosteroid therapy is administered. Full-thickness debridement without scleral patch graft could achieve elimination of infectious foci with favourable long-term anatomical and visual outcome. This technique could offer a potential last resort approach in such cases where standard therapeutic modalities have not been successful.
... Subconjunctival abscesses are usually caused by a bacterial infection associated with a previous trauma or surgery or may be secondary to a systemic infection. [1][2][3] Non-infectious etiologies are rarely reported but can occur spontaneously. [4][5][6] Described herein is a case of an aseptic systemic abscess presenting as a sterile subconjunctival abscess associated with ulcerative colitis (UC) which was successfully treated with high-dose glucocorticoids and tumor necrosis factor alpha inhibitor. ...
Purpose
To report a rare case of aseptic abscess presenting as a subconjunctival abscess in an HLA-B51-positive patient with ulcerative colitis.
Observations
A 25-year-old, male, Japanese patient with ulcerative colitis presented with an unilateral subconjunctival abscess. Infective endocarditis with endophthalmitis was suspected of being the cause, and systemic antimicrobial therapy was begun. The patient became critically ill and experienced the complication of heart failure with mitral valve perforation but improved dramatically with high-dose corticosteroids and intravenous infliximab following mitral valvuloplasty. His HLA typing was positive for HLA-B51.
Conclusions and importance
Both infectious and non-infectious etiologies should be considered in a patient with a subconjunctival abscess with systematic inflammation. An aseptic abscess can present as a subconjunctival abscess, and HLA-B51 may play a role in the pathogenesis of this rare condition.
