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| CASE REPORT |
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| Year : 1994 | Volume
: 42
| Issue : 2 | Page : 81-83 |
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Clinical course of scleritis induced by cataract surgery : A case report
Harsha Bhattacharjee1, Nitin Dutta2, Kasturi Das1
1 Regional Institute of Ophthalmology, Gauhati Medical College, Guwahati, India
2 Eye Hospital, R.G. Baruna Road, Guwahati, India
Correspondence Address:
Harsha Bhattacharjee
Regional Institute of Ophthalmology, Gauhati Medical College, Guwahati
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 7927636 
How to cite this article:
Bhattacharjee H, Dutta N, Das K. Clinical course of scleritis induced by cataract surgery : A case report. Indian J Ophthalmol 1994;42:81-3 |
Scleritis is a relatively rare granulomatous inflammation of the sclera or its adjacent vascular network. Involvement is generally bilateral with female preponderance. In 50% of cases it is associated with certain systemic disorders like rheumatoid arthritis, [1] tuberculosis [2] syphilis, [2] herpes zoster,[2] mumps [2] and toxoplasmosis. [3]sub The lesion is produced due to direct infection and/or due to microbial allergy. Different ocular surgeries can also induce both anterior and posterior scleritis. [4]
Anterior scleritis is generally associated with deep, severe and diffuse pain in the eye. Scleral inflammation and oedema are present under the episcleral congestion and swelling. Posterior scleritis causes vague discomfort on movement of the globe. Other features of posterior scleritis are proptosis, transitory choroidal folds in the fundus, choroidal oedema, and oedema of the sclera, Tenon's space and optic nerve sheath. The additional reported features are optic disc oedema, circumscribed fundus mass, choroidal detachment, exudative macular or retinal detachment, secondary choroiditis, and angle-closure glaucoma .[5],[6],[7]
| Case report | |  |
A 65-year-old diabetic male presented with a history of pain and redness in the right eye in the 6th postoperative week following uneventful intracapsular cataract extraction (ICCE). The cataract extraction was done through a limbal incision and the wound was closed with 8/0 interrupted sclerocorneal silk suture. A mild degree of redness and discomfort persisted postoperatively, with symptoms having worsened recently. The patient was using combined betamethasone and neomycin eye drops three times a day. On clinical examination, the best-corrected visual acuity in the right eye was 6/ 9. There was congestion and oedema on the suture sites, circumcorneal congestion, aqueous flare, muddy iris and sluggish pupillary reaction to light. The case was diagnosed as surgically induced sclerouveitis.
Sclerocorneal sutures were removed. The eye was treated with topical 1 % atropine eye drops four times a day, hourly instillation of betamethasone and neomycin eye drops, with oral indomethacin 25 mg four times a day. Within two weeks the scleritis became diffuse involving the entire exposed part of the globe. Oral prednisolone 100 mg on alternate morning was started and in two months time anterior sclerouveitis subsided. Diabetes was controlled with soluble insulin.
In the 10th month of the postoperative period, the patient again reported with rapidly progressive visual loss in the same eye (RE) of one month's duration with discomfort on ocular movement. On examination, the anterior segment was normal. Fundus examination revealed lower half exudative retinal detachment; a yellowish-white circumscribed fundus mass was situated in the posterior pole. The lesion was about five disc diameter in size. Visual acuity was reduced to perception of light only. Axial and transscleral serial sections on contact and water bath B-scan ultrasonography demonstrated diffuse choroidal and scleral thickening with increased acoustic density of the choroid and retinal detachment in the dependent part of the globe. The fundus sclerochoroidal mass lesion could be outlined. The base diameters were 15 X 18 mm with an apical height of 8 mm. The scleral lesion was seen to extend outside into the retroorbital fat and also protruded into the globe. The scleral lesion was bounded by sharply defined and smooth borders anteriorly, as well as posteriorly. It had little signal attenuation and minimal internal reflection. The overlying choroid showed circumscribed area of thickening manifested as a low profile convex lesion in the posterior pole, with mild ultrasonic internal reflectivity and minimal attenuation. The overall choroidal acoustic density was increased [Figure - 1][Figure - 2].
Systemic investigations, viz., complete blood picture and ESR were normal, LE cell preparation was negative. X ray chest was normal. The patient was treated with oral prednisolone 100 mg on a alternate day regime and oral ampicillin 500 mg four times a day for 10 days. Oral prednisolone was continued for one month, thereafter, finding no clinical response the drug was stopped. After one month, during a routine visit, a sub-Tenon abscess in the infero-temporal aspect of the eyeball was found and it was drained. Light microscopy of the material revealed eosinophilic inflammatory cells but no microorganisms. The suppuration continued for about one month. Thereafter, over a 4-month period, resolution of scleritis, choroidal effusion and fundus mass lesion occurred with reattachment of the retina. Visual acuity improved to counting fingers at 2 metres.
The case was finally diagnosed as surgically induced diffuse anterior sclerouveitis and on recurrence it manifested as secondary diffuse posterior scleritis complicated with diffuse choroidal effusion and localized inflammatory choroidal thickening underlying an area of scleral suppuration and exudative retinal detachment.
Fluorescein angiography study showed diffuse hyperfluorescence of the posterior pole with multiple window defects due to retinal pigment epithelial atrophy. No recurrence of the disease was noted during the 21/2 year postoperative follow-up period.
| Discussion | | |
Intraocular complications of posterior scleritis like choroidal effusion and exudative retinal detachment are rare. In such situations, the condition is to be differentiated from choroidal tumours like melanoma, haemangioma, and metastatic tumours. Other causes of choroidal effusion are arteriovenous fistula, panretinal photocoagulation, buckling procedure for retinal detachment, and those following any intraocular surgery. [2] The diagnosis of such conditions depend on findings of ultrasonography and CT scan. B-scan ultrasonography demonstrates choroidal and scleral thickening, and associated increased acoustic density of the choroid. [8]
In about 96% of instances surgically induced scleritis is of necrotising variety. Scleral inflammation develops adjacent to a surgical wound and in 23% of cases there is associated secondary posterior scleritis. Different procedures like cataract extraction, glaucoma, strabismus, and retinal detachment surgery can induce scleritis. Of these, cataract extraction through a limbal incision comprises the largest subgroup. Majority of such cases (75%) generally undergo two or more ocular surgical procedures before the onset of scleritis. The reported latent period between ocular surgery and the appearance of the inflammation is about 9 months but it may also occur after several years in a small group of cases. Threefifths of such cases possess a history of systemic disorder . [4]
The present case had certain distinctive features. The patient was a male with diabetes mellitus. The initial presentation of the postoperative complication was sclerbuveitis. Though at the onset the scleral inflammation was localized in the cataract section, it progressed to diffuse anterior scleritis with no scleral necrosis. This differentiates it from the usual surgically induced scleritis, which is generally of the necrotising variety. Recurrence of the scleritis was manifested as delayed posterior scleritis with intraocular manifestations, six months after complete resolution of anterior scleritis. The initial episode of scleritis was steroid responsive but the recurrent attack was steroid resistant. Secondary posterior scleritis and the associated intraocular manifestations resolved following partial suppuration of the sclera, which was clinically presented as a sub-Tenon abscess needing drainage. This suppuration had a decompressive effect on the globe. The thickened sclera might have interfered with the transscleral flow of fluid to give rise to choroidal effusion and exudative retinal detachment. B-scan ultrasonography helped to distinguish the condition from intraocular malignancy. The history, natural course of the disease, negative systemic findings, the clinical presentation, and ultrasonographic findings, were the basis of the present clinical diagnosis. This complication of cataract surgery is not reported in the literature to the best of our knowledge.
| References | | |
| 1. | Lyne AJ. Scleritis and systemic disease. Trans Ophthalmol Soc UK. 94:58; 1974.  |
| 2. | Watson PG, Hazelman BL. Clinical Examination of the eye in Scleral disease and Systemic disorders. Philadelphia, WB Saunders Co. 1976. |
| 3. | Schuman JS, Weinberg RS, Ferry AP, et al. Toxoplasmic Scleritis. Ophthalmology. 95:1399-1403, 1988. |
| 4. | Lightman S, Tuft S, Watson P. Surgically induced necrotising sclerokeratitis (SINS) - Precipitating factors and response to treatment. Br J Ophthalmol. 76:17-21, 1992. |
| 5. | Singh G, Guthoff R, Foster CS. Observations on longterm follow-up of posterior scleritis. Am J Ophthalmol. 101:570-575, 1986. |
| 6. | Benson WE. Posterior Scleritis. Surv Ophthalmol. 32:297-316, 1988. |
| 7. | Leitch RJ, Bearn MA, Watson PG. Exudative retinal detachment and posterior scleritis associated with massive scleral thickening and calcification treated by scleral decompression. Br J Ophthalmol. 76:109-112, 1992. |
| 8. | Wald KJ, Spaide R, Patalano VJ, et al. Posterior Scleritis in Children. Am J Ophthalmol. 113:281-286, 1992. |
[Figure - 1], [Figure - 2]
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