Management of Scleral Thinning : An Alternate Approach - PDF Document

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  1. NUJHS Vol. 6, No.1, 2016, ISSN 2249-7110 March Nitte University Journal of Health Science Case Report Management of Scleral Thinning : An Alternate Approach 1 2 3 4 Vijay Pai Jayaram Shetty , Hrishikesh Amin & Manu Thomas , 2 4 Professors, Professor & HOD, Postgraduate, Department of Ophthalmology, K.S. Hedge Medical Academy, Nitte University, Mangalore, Karnataka, India. 1,3 Correspondence Vijay Pai Professor, Department of Ophthalmology, K.S. Hedge Medical Academy, Nitte University, Mangalore - 575 108, Karnataka, India. E-mail : eyevijay@yahoo.com Abstract A5yearoldchildpresentedwithcorneo-scleraltearinhislefteyefollowingtraumawithknifewhichwasrepairedimmediately.1month latertherewasthinningofthescleraatthesuturedsite.Analternateapproachwasproposedforthemanagementofscleralthinning. Anautologousscleralpatchgraftfromthesameeyewassuturedattheareaofthinning.Thismethodwasfoundtobemoreconvenient andeasytoperform.Sincethegraftwasstableandthedonorsitewashealthy;thismethodcanbeusedasanalternativeapproachfor themanagementofscleralthinning. Keywords:Scleralthinning,autologousscleralpatchgraft,Donorsclera Introduction same eye is described here. The ease of availability of a Thescleraistheouterfibrouscoatwhichprovidesastable viable tissue and no risk of rejection were the major support for the intraocular contents. There are various advantages. Therefore, this procedure is convenient for causes for scleral thinning such as, chronic scleritis, scleral emergencycasesaswell. 1,2 injuriesfollowingtraumaorpterygiumsurgery ,excessive CaseHistory use of cautery on scleral bed, over use of antimetabolites A 5 year old boy presented to the Department of like mitomycinfor pterygium and trabeculectomy Ophthalmology with trauma to his left eye with knife. On 3 4 surgeries , adjunctive irradiation , strabismus surgery, examination, there was a linear full thickness corneo- deep sclerotomy procedures, high myopia and systemic scleraltearofabout4mminlengthextendingabout3mm 1,5 vasculitis. into the sclera at the 6'o clock limbus. The corneo-scleral tearrepairwasdonewith10-0interruptedsutures. In rare instances, it may result in staphyloma formation, scleral perforation, and uveal exposure. Therefore, 1monthpostoperatively,a3x3mmareaofsclerathinning reinforcement of the thinor perforatedsclera isnecessary was noted 2 mm from the 6'o clock limbus with ciliary to prevent prolapse of ocular contents and secondary staphyloma.Healsodevelopedtraumaticcataract.(Figure 1 infection. 1)Anautologousscleralpatchgraftfromthepatient'sown eye with cataract extraction and PCIOL implantation was Varioussurgicalapproachesforthemanagementofscleral planned. 5,6,7 thinning are donor scleral lamellar patch graft , multilayered amniotic Apartialthicknessfreescleralpatchgraftofabout3x3mm 8 membrane grafting , Access this article online Quick Response Code size was fashioned from the upper temporal quadrant at 9 lamellar corneal graft , the equatorial region of the sclera of the same eye after 10 rotational scleral graft raising a fornix based conjunctival flap. The edges of the and autologous scleral thinned out sclera at 6'o clock was freshened after raising 11,12 patchgraft. the conjunctival flap. The scleral patch graft was carefully positioned at the area of scleral thinning and secured with An autologous lamellar 10-0 interrupted nylon sutures and was covered with the scleralpatchgraftfromthe 88

  2. NUJHS Vol. 6, No.1, 2016, ISSN 2249-7110 March Nitte University Journal of Health Science conjunctival flap. In the same sitting, cataract extraction andinthebagPCIOLimplantationwasdone. st 1 post-operative day, the scleral patch graft was stable. (Figure 2)Patient was discharged on the 3rd day with Fig. 4 : Graft taken up well at six weeks postoperative period systemic antibiotics, analgesics, oral prednisolone 20mg/day, antibiotic-steroid eye drops hourly and mydriatriceyedropsthricedaily.At1monthfollowup,the scleralpatchgraftwaswellapposedandtherewasnosigns ofuvealtissueexposure.(Figure3) Fig. 1 : Area of thinning 2mm below 6'o clock limbus with ciliary staphyloma(preoperative) At 6 weeks, the graft uptake was good, the donor site was healthy and there was no evidence of ectasia.(Figure 4) At thispointtheexposedsutureswereremovedcarefully. Discussion Scleralthinningormeltisaseriousandchallengingclinical problem as it threatens the integrity of the eye. Different grafts used for scleral thinning include amniotic membrane, sclera, cornea, fascia lata, cartilage, cadaveric 1,5,6 aortic tissue, tibial periosteum and skin. Literature on Fig. 2 : postoperative day 1 following scleral patch grafting, cataractextractionandPCIOLimplantation autologousscleralgraftfromsameeyeislimited.However, variousothertechniqueshavebeendescribed. 11 Polat has described successful repair with autologous lamellar scleral patch graft for scleral melt following 12 pterygiumsurgerywithmitomycinC.Prydal hasreported the repair of peripheral corneal perforation with autologous lamellar scleral patch graft. This procedure is beneficial in emergency cases as there is no hassle of waitingfordonortissue. A rotational pedicle scleral graft can be done if the area of 10 thinning is small and surrounding sclera is healthy. In our case, the surrounding sclera was unhealthy, therefore we Fig. 3 : A well apposed scleral patch graft 1 month postoperatively 89

  3. NUJHS Vol. 6, No.1, 2016, ISSN 2249-7110 March Nitte University Journal of Health Science scleromalaciaincaseswheretheadjacentconjunctivawas didnotoptforathisprocedure. deficient. Rapid re-epithelialization of ocular surface was Donor sclera is well-tolerated by the host with little noted. inflammatory reaction and rare rejections and can be 1 Another rare entity, surgically induced scleral necrosis preserved for months. It is strong, flexible and allows a 7 (SINS),alocalisedautoimmunereactionoccurringatasite better fit to the host defects. But complications such as ofprevioussurgicalwoundalsocausedscleralthinning.Itis necrosisandmeltingofgraft,dehiscencecanbeavoidedby known to occur after cataract extraction by a limbal promoting epithelization and vascularization of the incision, strabismus surgery, trabeculectomy and retinal avascular scleral patch graft by covering with conjunctival 13,14 6 detachmentsurgery. flaporanamnioticmembranegraft. 9 The limitations of autologous scleral patch graft is the Ti et al , reported the use of corneal lamellar graft to inability to take large grafts to cover large areas of scleral maintain integrity of the globe in cases of scleral melting thinning.Incaseslikehighmyopes,wherethescleraisthin after pterygium surgery. The disadvantage was its overall, there is a risk of perforation while creating a graft. transparency making it cosmetically unacceptable to the However, ifthe sclera ishealthy and the areaof thinning is patient. small, an autologous lamellar scleral autograft is a safe Amniotic membrane consists of a thick basement procedure. membrane and an avascular stroma. It has anti- To the best of our knowledge, an autologous lamellar inflammatory and epithelialization promoting properties. scleral patch graft with cataract extraction and PCIOL But it may not provide adequate tectonic rigidity and is implantation in the same sitting is being reported for the 1 6 amenabletorapiddisintegrationandloss. Hwan,Kimetal firsttimehere. described scleral grafting with amniotic membrane for References 1. V, Jain V, Gupta P. Structural and functional outcome of scleral patch graft.Eye.2007;21(7):930-5. 2. AlsagoffZ,TanDT,CheeS.Necrotisingscleritisafterbarescleraexcision ofpterygium.Britishjournalofophthalmology.2000;84(9):1050-2. 3. RubinfeldRS,PfisterRR,SteinRM,FosterCS,MartinNF,StoleruS,etal. Seriouscomplicationsoftopicalmitomycin-Cafterpterygiumsurgery. Ophthalmology.1992;99(11):1647-54. 4. Mackenzie FD, Hirst LW, Kynaston B, Bain C. Recurrence rate and complications after beta irradiation for pterygia. Ophthalmology. 1991;98(12):1776-81 5. Nguyen QD, Foster CS. Scleral patch graft in the management of necrotizing scleritis. International ophthalmology clinics. 1999;39(1):109-31. 6. Oh JH, Kim JC. Repair of scleromalacia using preserved scleral graft with amniotic membrane transplantation. Cornea. 2003;22(4):288- 93. 7. Stunf S, Lumi X, Drnovšek-Olup B. Preserved scleral patch graft for unexpected extreme scleral thinning found at the scleral buckling procedure: A case report. Indian journal of ophthalmology. 2011;59(3):235. 8. Sridhar M, Bansal A, Rao G. Multilayered amniotic membrane transplantation for partial thickness scleral thinning following pterygiumsurgery.Eye.2002;16(5):639-42. 9. Ti S-E, Tan DT. Tectonic corneal lamellar grafting for severe scleral melting after pterygium surgery. Ophthalmology. 2003;110(6):1126- 36 10.KumarDA,AgarwalA,NairV,JacobS,PrakashG,AgarwalA.Rotational LamellarScleralFlapfortheManagementofPosttrabeculectomyBleb Leak.Eye&contactlens.2013;39(4):e21-e4. 11.PolatN.UseofanAutologousLamellarScleralGrafttoRepairaScleral Melt AfterMitomycin Application. Ophthalmology and therapy. 2014;3(1-2):73-6. 12.PrydalJ.Useofanautologouslamellarscleralgrafttorepairacorneal perforation.TheBritishjournalofophthalmology.2006;90(7):924. 13.Mahmood S, Suresh P, Carley F, Bruce I, Tullo A. Surgically induced necrotisingscleritis: report of a case presenting 51 years following strabismussurgery.Eye.2002;16(4):503-4 14.Joseph A, Biswas J, Sitalakshmi G, Gopal L, Badrinath S. Surgically inducednecrotisingscleritis(SINS)-Reportoftwocases.Indianjournal ofophthalmology.1997;45(1):43 90