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Scleritis and Retinal Detachment After Strabismus Surgery in a Patient With Thyroid Eye Disease

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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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Article Information

Corresponding Author: Asim V. Farooq, MD, Department of Ophthalmology and Visual Science, University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637 (asimfarooq@uchicago.edu).

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.

References
1.
Doshi  RR , Harocopos  GJ , Schwab  IR , Cunningham  ET  Jr .  The spectrum of postoperative scleral necrosis.   Surv Ophthalmol. 2013;58(6):620-633. doi:10.1016/j.survophthal.2012.11.002PubMedGoogle ScholarCrossref
2.
O’Donoghue  E , Lightman  S , Tuft  S , Watson  P .  Surgically induced necrotising sclerokeratitis (SINS).   Br J Ophthalmol. 1992;76(1):17-21. doi:10.1136/bjo.76.1.17PubMedGoogle ScholarCrossref
3.
Seo  KY , Lee  HK , Kim  EK , Lee  JH .  Expression of tumor necrosis factor alpha and matrix metalloproteinase-9 in surgically induced necrotizing scleritis.   Ophthalmic Res. 2006;38(2):66-70. doi:10.1159/000090010PubMedGoogle ScholarCrossref
4.
Joseph  A , Biswas  J , Sitalakshmi  G , Gopal  L , Badrinath  SS .  Surgically induced necrotising scleritis (SINS).   Indian J Ophthalmol. 1997;45(1):43-45.PubMedGoogle Scholar
5.
Alsagoff  Z , Tan  DT , Chee  SP .  Necrotising scleritis after bare sclera excision of pterygium.   Br J Ophthalmol. 2000;84(9):1050-1052. doi:10.1136/bjo.84.9.1050PubMedGoogle ScholarCrossref
6.
Mahmood  S , Suresh  PS , Carley  F , Bruce  IN , Tullo  AB .  Surgically induced necrotising scleritis.   Eye (Lond). 2002;16(4):503-504. doi:10.1038/sj.eye.6700033PubMedGoogle ScholarCrossref
7.
Lai  T , Leibovitch  I , Zadeh  R , Chehade  M , Tamblyn  D , Selva  D .  Surgically induced necrotizing scleritis occurring 48 years after strabismus surgery.   J Pediatr Ophthalmol Strabismus. 2005;42(3):180-182. doi:10.3928/01913913-20050501-07PubMedGoogle ScholarCrossref
8.
Akpek  EK . Necrotizing scleritis: diagnosis and therapy. Published 1994. Accessed August 14, 2020. http://www.uveitis.org/docs/dm/ necrotizing_scleritis_diagnosis_therapy.pdf
9.
Ram  R .  Tectonic corneal lamellar grafting for surgically-induced necrotizing scleritis after strabismus surgery.   Am J Ophthalmol Case Rep. 2018;11:28-31. doi:10.1016/j.ajoc.2018.04.025PubMedGoogle ScholarCrossref
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