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A 74-year-old man with an ocular history of bilateral cataract extraction 9 years prior and left inferior rectus muscle recession 3 months before this current evaluation for 2 months of severe, progressive pain, redness, and decreased visual acuity in the left eye. After strabismus surgery, he was noted to have a nonhealing conjunctival epithelial defect inferiorly, which later developed underlying scleral thinning. He was being treated with topical moxifloxacin, 0.5%, every 2 hours in the left eye. He noted a medical history of hyperthyroidism, coronary artery disease, hypertension, and type 2 diabetes mellitus. He also noted a history of substantial blood glucose elevation after taking oral prednisone.
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Necrotizing scleritis associated with surgery
D. Initiate admission, high-dose systemic steroids, and a rheumatology consult.
Given that the patient had recent strabismus surgery and signs of scleritis with focal necrosis near the surgical site, iris neovascularization, and exudative retinal detachment, necrotizing scleritis associated with surgery was considered to be the unifying diagnosis. Necrotizing scleritis is a rare complication of ophthalmic surgery that typically presents as a focal area of intense scleral inflammation at the site of a previous surgery.1 It is thought to be a local autoimmune reaction and can be associated with systemic diseases, such as rheumatoid arthritis, granulomatosis with polyangiitis, thyroid disease, and type 1 diabetes mellitus. Histology of involved sclera shows a delayed-type hypersensitivity reaction, the nature of which is not fully understood.2,3 One theory is that surgical trauma exposes antigens from a normally immune-privileged site; following surgery, the immune system may produce antibodies to these newly exposed antigens. Exudative retinal detachment with necrotizing scleritis associated with surgery is very rare.4
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Corresponding Author: Asim V. Farooq, MD, Department of Ophthalmology and Visual Science, University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637 (firstname.lastname@example.org).
Published Online: September 17, 2020. doi:10.1001/jamaophthalmol.2020.2034
Conflict of Interest Disclosures: Dr Skondra reported personal fees from Allergan outside the submitted work. No other disclosures were reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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