Surgically-Induced Necrotizing Scleritis After Scleral Buckling With Stenotrophomonas maltophilia Infection

Abstract

Surgically induced necrotizing scleritis (SINS) is a rare inflammatory disease of the sclera that occurs following ocular surgery, specifically pterygium surgery and scleral buckling. Here, we report a case of SINS in a 78-year-old female patient after segmental scleral buckling for rhegmatogenous retinal detachment. The retina was restored after scleral buckling, and the postoperative course was uneventful. However, the patient developed ocular discharge and conjunctival hyperemia, indicating infection, after two months. The sclera became thinner and intraocular inflammation developed after buckle removal. Stenotrophomonas maltophilia was isolated from the ocular discharge, and the patient was treated with antibacterial agents susceptible to the bacteria. However, her symptoms persisted, and corrected visual acuity decreased from 20/25 to 20/1000. Oral steroid treatment was initiated because of the suspicion of SINS. Intraocular inflammation gradually subsided, the thin sclera was covered by conjunctival tissue, and the patient's corrected visual acuity improved to 20/32, which stabilized her condition. Infection with Stenotrophomonas maltophilia after scleral buckling is extremely rare, and SINS development in such cases is unprecedented.

Keywords: postoperative complications; scleral buckle infection; scleral necrosis; stenotrophomonas maltophilia infection; surgically induced necrotizing scleritis.

Figure 1. Segmental scleral buckling restored retina (left eye images)

(A) A silicone sponge buckle (arrowheads) is inserted under the superior rectus muscle (arrow) and fixed. (B) The retinal tear (arrows) is closed by buckling.

Figure 2. Postoperative inflammation (all left eye images)

(A) Two months after the initial surgery, the upper conjunctival hyperemia and ocular discharge demonstrated an ocular surface stained with fluorescein), but with no buckle exposure on the conjunctiva. (B) Fundus image 10 days after buckle removal; there is no evidence of retinal redetachment, but the area of previous detachment has atrophic changes. (C) Three months after the initial surgery; the sclera in the area where the buckle was removed is necrotic (arrows). (D) Multiple muton fat-like keratic precipitates are seen on the posterior cornea.

Figure 3. After anti-inflammatory therapy for SINS (left eye images)

(A) The choroid in the scleral necrosis area is covered with conjunctival tissue and appears grayish-white two years after scleral buckling. (B) Anterior segment inflammation has disappeared two years after scleral buckling. SINS: Surgically induced necrotizing scleritis