Scleral Ischemia & Melt Literature Summary
Scleral ischemia, thinning and melt can occur in acute severe chemical or thermal burns and following ocular surgeries such as pterygium excision with a bare sclera technique,1 especially if such adjuvant therapies as betairradiation and mitomycin C are used.2 In addition, scleral melt has also been described after retinal detachment repair, glaucoma surgery, systemic vasculitis and connective tissue disorders.3,4 Reim et al first described the use of Tenonplasty as an excellent alternative to treat limbal and scleral ischemia in patients with severe chemical and thermal eye burns in 1989 to facilitate conjunctival healing and to halt progressive scleral melt.5,6 Since then, several reports have been published reassuring the effectiveness of this surgical approach.7-9 Lin et al9 in 2002 reported the use of Tenonplasty and amniotic membrane transplantation in 6 patients with scleral perforation after pterygium surgery. There were no recurrences during a follow-up period of 12 to 24 months.
On the other hand, when severe scleral thinning or melt with impending globe perforation is evident, sclera reinforcement is necessary. Different types of tissue grafts have been proposed and/or actually used to fulfill this purpose. They include preserved sclera, cornea, pericardium, fascia lata, dura, conjunctiva, amniotic membrane, etc.9,10 None of the proposed grafts have been universally accepted. Lin et al11 in 1996 described a method for scleral grafting using preserved sclera and tissue adhesive with an overlying conjunctival flap, and noted good results in 5/6 cases with infectious scleral ulcers. Rodriguez-Ares et al12 successfully used scleral graft and amniotic membrane transplant to repair a large scleral perforation in a patient with Marfan’s syndrome and a past history of various surgeries in both eyes. Hanada et al,13 used multilayered amniotic membrane transplantation for the treatment of 11 patients (11 eyes) with deep corneal ulcers (n=5), corneal perforations (n=4) and scleral ulcers (n=2). After surgery 8/11 eyes, including 2 cases with scleral defects did properly heal. Ma et al14 used cryopreserved amniotic membrane as a patch graft to reduce stromal melting and promote reepithelialization in four cases of infectious scleral ulcers with persistent scleral melting and three cases with corneoscleral ulcers with perforation. They noted that melting and inflammation at the lesion site decreased after the amniotic membrane grafting. It should be noted that in all their cases the causative microorganisms were identified and the appropriate topical and systemic antibiotics were given to all patients before the surgery. Oh et al15 performed a prospective study in 8 eyes (8 patients) using preserved sclera and amniotic membrane transplantation for the surgical repair of scleromalacia with impending perforation. All patients experienced loss of ocular pain and inflammation and rapid epithelialization. Ti et al10 reported the successful use of tectonic corneal lamellar grafting with overlying conjunctival flap in 95% of their cases (19/20 patients) with severe scleral melts after pterygium surgery with mitomycin C or beta irradiation. Golchin et al16 reported lamellar keratoplasty as an effective treatment option for scleral necrosis induced by beta irradiation, achieving tectonic restoration in all of their patients (30 eyes). Most recently Sangwan et al3 retrospectively evaluated the outcome of alcohol preserved scleral patch grafts in conjunction with overlying conjunctival flaps or amniotic membrane, in patients (n=13) with scleral defects of varying etiologies, and noted this approach was effective in preserving the globe integrity in 77% of these cases.
References
1. Alzagoff Z, Tan TD, Chee SP. Necrotising scleritis after bare sclera excision of pterygium. Br J
Ophthalmology. 2000;84(9):1050-1052.
2. Tsai YY, Lin JM, Shy JD. Acute scleral thinning after pterygium excision with intraoperative mitomycin
C: a case report of scleral dellen after bare sclera technique and review of the literature. Cornea. 2002;21(2):227-229.
3. Sangwan VS, Jain V, Gupta P. Structural and functional outcome of scleral patch graft. Eye. 2006:1-6.
4. Ozcan AA, Bilgic E, Yagmur M, Ersoz TR. Surgical management of scleral defects. Cornea. 2005;24(3):308-11.
5. Teping C, Reim M. Tenonplasty as a new surgical principle in the early treatment of the most severe chemical eye burns. Klin Monatsbl Augenheilkd. 1989;194(1):1-5.
6. Kuckelkorn R, Redbrake C, Reim M. Tenonplasty a new surgical approach for the treatment of severe eye burns. Ophthalmic Surg Lasers. 1997;28(2):105-10.
7. Wagoner MD. Chemical injuries of the eye: current concepts in pathophysiology and theraphy. Surv Ophthalmol. 1997;41(4):275-313.
8. White WL, Hollsten DA. Burns of the ocular adnexa. Curr Opin Ophthalmol. 1994; 5(5):74-7.
9. Lin HC, Ku WC, Lin KK, Tsai RJ. Surgical management of scleral perforation after pterygium surgery. Ophthalmic Surg Lasers. 2002;33(4):275-9.
10. Ti SE, Tan DT. Tectonic Corneal lamellar grafting for severe scleral melting after pterygiumurgery. Ophthalmology. 2003;110(6):1126-36.
11. Lin C.P, Tsai MC, Wu YH, Shin MH. Repair of a giant scleral ulcer with preserved sclera and tissue adhesive. Ophthalmic Surg Lasers. 1996;27(12):995-9.
12. Rodriguez-Ares MT, Tourino R, Capeans C, Sanchez-Salorio M. Repair of scleral perforation with preserved sclera and amniotic membrane in Marfan’s syndrome. Ophthalmic Surg Lasers. 1999;30(6):485-7.
13. Hanada k, Shimazaki J, Shimmura S, Tsubota K. Multilayered amniotic membrane transplantation for severe ulceration of the cornea and sclera. Am J Opthalmol. 2001;131(3):324-31.
14. Ma DH, Wang SF, Su WY, Tsai RJ. Amniotic membrane graft for the management of scleral melting and corneal perforation in recalcitrant infectious scleral and corneoscleral ulcers. Cornea. 2002;21(3):275-83.
15. Oh JH, Kim JC. Repair of scleromalacia using preserved scleral graft with amniotic membrane transplantation. Cornea. 2003;22(4):288-93.
16. Golchin B, Butler TK, Robinson LP, Weschesler AW, Sutton G, Robinson DI, McClellan K. Long-term follow-up results of lamellar keratoplasty as a treatment for recurrent pterygium and for scleral necrosis induced by beta-irradiation. Cornea. 2003;22(7):612-8).
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