Case Reports

Toxic serpentine scleral necrosis: is it really obsolete?

Case Report Details

First Author: R.Agarwal INDIA

Co Author(s):    C. Chetan   N. Sharma                 

Abstract Details

Purpose:

Anterior scleritis is a sight-threatening ocular inflammation directed against the sclera by infectious or non-infectious causes. Local steroids can be used for the management of non-necrotising non-infectious anterior scleritis, either nodular or diffuse in nature. Although it delivers high tissue levels of steroid at the targeted area, it can have its own complications such as raised intraocular pressure (steroid response), glaucoma, development or worsening of cataract and ptosis. Progressive scleral necrosis is a one such rare adverse event that can be witnessed after subconjunctival steroid injection (SCI). Presently, we report a case of progressive anterior scleral necrosis associated with SCI.

Setting:

Dr Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi.

Report of Case:

A 45-year old male complaining of localized redness in upper part of right eye, diagnosed as nodular anterior scleritis, was administered subconjunctival triamcinolone acetate (SCTA) 4mg adjacent to the nodule after non-response to topical prednisolone acetate 1% for 4-months elsewhere. However, 3-weeks after SCTA administration, he had diffuse congestion, engorged conjunctival blood vessels, 10 clock hours anterior scleral necrosis spreading clockwise from 12ó clock to 10ó clock, a 1×0.5mm large superiorly placed whitish depot of SCTA 4mm from the limbus, anterior segment flare (no cells), few posterior synechiae and nuclear sclerosis grade-1 in right eye and a normal left eye. Ultrasound biomicroscopic imaging and contrast enhanced computerized tomography both showed a localized outpouching of sclera and buckling of anterior scleral wall superiorly. A comprehensive blood profile and systemic evaluation was found negative. A diagnosis of Toxic serpentine scleral necrosis associated with SCTA was made and the patient was managed conservatively. The patient showed gradual improvement on topical lubricants and oral indomethacin 75mg twice daily, with no recurrence of disease or residual depot of SCTA at 6-months and later at 2-years follow-up.

Conclusion/Take Home Message:

The role of SCIs for treatment of non-necrotising non-infectious anterior scleritis has always been controversial. While early experience with SCIs in the 1970s discouraged their use because of concerns of poor efficacy and risk of sight-threatening scleral necrosis or perforation, further studies have established their long-term safety and efficacy for non-responsive non-necrotising anterior scleritis. By reporting this case, we do not discredit the utility of SCIs in anterior scleritis. However, we advocate a cautious use of these agents for the same.

Financial Disclosure:

None