Interactive Case Reports

Combined triple procedure for a hard-dense cataract associated with severe iatrogenic scleromalacia: preserved scleral graft patching, amniotic membrane transplantation and phaco-chop phacoemulsification

Case Report Details

First Author: L.Pareja Arico SPAIN

Co Author(s):    J. Herreras Cantalapiedra   G. Pacheco Callirgos   D. Galarreta Mira              

Abstract Details

Purpose:

Scleromalacia is a dangerous eye condition leading to high risk of globe perforation. Procedures like phacoemulsification in patients affected by this condition are in most of cases contraindicated because of the intraoperative infusion associated risks. The purpose of this case is to report a combined procedure of scleral patching and amniotic membrane transplantation prior to phacoemulsification in a case of iatrogenic scleromalacia associated with a hard-dense cataract.

Setting:

Ocular Surface Reconstruction Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.

Report of Case:

A 65-year old woman who underwent an unspecified bilateral glaucoma procedure 10 years ago reported pain and decreased visual acuity in both eyes which had developed 2 months prior ophthalmology visit. Best corrected visual acuity was 0.05 in her right eye and 0.6 in her left eye during the first visit. Slit lamp examination of the right eye showed a grade NC5 NO5 cataract (LOCS cataract classification system III) associated with a 6 mm * 4 mm marked scleral thinning with choroid exposure in the superior portion of the eye. Fundus ophthalmoscopy of the right eye was not possible to perform due media opacity. Ocular echography showed no evidence of retinal pathology. Slit lamp examination of the left eye showed a grade NC2 NO2 cataract associated with a 3 mm * 2 mm scleral thinning with choroid exposure in the superior portion of the left eye (less severe than in the contralateral eye) Fundus ophthalmoscopy was normal. Cataract extraction of the right eye was indicated due severe visual impairment. Considering the patient’s scleromalacia, it was decided to previously repair it with scleral graft patch and amniotic membrane transplantation. During the procedure, superior rectus muscle was disinserted from the thinned sclera, reattached to the scleral graft and covered with conjunctival suture and amniotic membrane transplantation. Once the patch was made, cataract surgery was performed using phaco chop technique, with good tolerance of the patch to high infusion-vacuum rates. Postoperatively, best corrected visual acuity arrived to 0.5, scleral patch and amniotic membrane has adapted well with no evidence of uveal explosion and superior rectus reinsertion did not caused diplopia. Systemic immunosuppression with low dose oral corticoids is maintained in order to avoid patch rejection or reabsorption.

Conclusion/Take Home Message:

Repair of severe scleromalacia using preserved scleral graft and amniotic membrane transplantation is a well-tolerated option that could lead to perform a safe phacoemulsification during the same surgical time in cases when this pathology coexists with a cataract. With prior repair of scleromalacia using scleral graft patch and amniotic membrane is possible to avoid severe fluidic-derived complications leading to globe perforation during phacoemulsification or more stressful surgeries like an extracapsular procedure. However, more cases and follow up time are needed to evaluate the potential influence of cataract related inflammation process into the tolerance and adaptation of scleral patches.

Financial Disclosure:

None