A Severe Case of Infectious Necrotizing Anterior Scleritis Caused by Pseudomonas aeruginosa after Vitreoretinal Surgery

Abstract

Introduction: This report describes a case of necrotizing scleritis caused by Pseudomonas aeruginosa infection soon after vitreous surgery, which caused severe scleral melting and rapidly progressive necrosis that led to scleral perforation and bacterial endophthalmitis.

Case presentation: The patient was an 86-year-old man with a history of type 2 diabetes mellitus who underwent pars plana vitrectomy (PPV) for vitreous hemorrhage in his right eye. On postoperative day 10, he complained of severe ocular pain and was found to have conjunctival edema and eyelid swelling, which was treated by topical and general systemic antibiotics. His ocular symptoms improved but subsequently worsened. On postoperative day 25, hypopyon and a fibrinous exudative membrane were observed in the anterior chamber, and the fundus could not be visualized. PPV was repeated with addition of silicone oil tamponade. During the surgery, the retina was found to be completely detached with severe anterior scleral melting, perforation, and necrosis, as well as abscess formation. Culture of an eye discharge specimen detected P. aeruginosa. After surgery, antibiotics were administered and the eye was washed with polyvinyl alcohol-iodine solution daily. Ten days later, the eye pain and eyelid swelling were significantly improved. The scleral inflammation gradually resolved without recurrence.

Conclusion: In this case, rapidly progressive necrotizing scleritis caused by P. aeruginosa infection was controlled by a combination of antibiotics, removal of necrotic tissue, and daily eye washing with polyvinyl alcohol-iodine solution.

Keywords: Necrotizing scleritis; Polyvinyl alcohol-iodine solution; Pseudomonas aeruginosa; Scleral necrosis.

Fig. 1.

a Clinical photograph taken immediately before the second surgery (25 days after the first surgery) showing hypopyon and a fibrinous exudative membrane in the anterior chamber. b Intraoperative fundus photograph obtained during the second surgery showing complete detachment of the retina.

Fig. 2.

Photographs taken during the second surgery. a The anterior sclera had melted widely (arrowhead), and the choroid is exposed because of scleral thinning. b Scleral necrosis formation is observed (arrowhead), especially around the port site used for the previous surgery. c A portion of the sclera was too fragile for insertion of a port for PPV because of severe melting (arrowhead). d The anterior sclera showed widespread melting and was too fragile for suturing (arrowhead).

Fig. 3.

Findings on slit-lamp examination and fundus photographs of the right eye showing the clinical course. a On the day after surgery, slit-lamp examination showed corneal edema, scleral melting, conjunctival edema, and a fibrinous exudative membrane in the anterior chamber. b Ten days after surgery, the corneal edema and fibrinous exudative membrane were significantly improved. c One month after surgery, the corneal edema, conjunctival edema, and conjunctival injection showed significant improvement. d Three months after surgery, the conjunctival injection was significantly improved. e Ten months after surgery, the scleral wound was completely healed and the conjunctival inflammation had resolved completely without recurrence. f Ten months after surgery, there was no recurrence of retinal detachment or relapse of intraocular inflammation after silicone oil tamponade.