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October consultation #2

McLeod, Stephen D. MD

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Journal of Cataract & Refractive Surgery: October 2014 - Volume 40 - Issue 10 - p 1748
doi: 10.1016/j.jcrs.2014.08.005
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This case describes avascular scleral necrosis with a calcific plaque occurring in a young man who previously had a “cosmetic eye-whitening procedure…in California.” Unfortunately, this fits the description of iatrogenic avascular scleromalacia due to cosmetic conjunctivectomy and tenonectomy combined with mitomycin-C (MMC), as performed in the so-called I-Brite procedure. This procedure was introduced in 2008 and was popularized to some extent in Asia, despite concern over complications including scleromalacia, as described in this case. Rhiu et al.1 report a series of 44 patients in Korea who had this procedure, which resulted in complications that included, among others, chronic corneal epithelial defects; scleral thinning, often with calcific plaques similar to those documented in this patient; and strabismus due to fibrovascular conjunctival and Tenon capsule adhesions at the muscle insertion.

In the case presented here, the scleral necrosis is due to loss of the local vascular supply rather than to inflammation and no active anterior chamber reaction is observed; thus, antiinflammatory treatment is not warranted. However, the patient reports foreign-body sensation and pain, which is likely associated with the calcific plaque. Rhiu et al.1 describe treating these patients with lubrication and autologous serum. However, it is unclear what role this plays in the setting of scleral degeneration. Most commonly, we consider autologous serum as an adjuvant in promoting reepithelialization of the cornea, and although unproved, this may prompt consideration for its use to promote conjunctival reepithelialization. A similar case seen at the University of California, San Francisco, was successfully treated simply with removal of the calcific plaque, which exposed an intact but denuded underlying sclera that subsequently reepithelialized without recurrence of the plaque at the time of this writing.

In the event of a persistent conjunctival defect in this location, and indeed with regard to the right eye, which seems to have extensive loss of viable conjunctiva, one might have to consider an amniotic membrane graft or a conjunctival graft from the superior bulbar conjunctiva.2 If a conjunctival graft is chosen, one would want to confirm that the donor site retains a healthy blood supply to minimize the chance of poor healing. In this setting, there is a risk for infectious scleritis involving bacterial and fungal agents; this should be ruled out with cultures and treated aggressively topically and systemically if identified.

In the absence of concurrent infection, the immediate goal of therapy is the reestablishment of viable conjunctiva over the entire sclera free of calcific plaque. This would be expected to arrest underlying scleral thinning. For the long term, we have little experience to guide us. The best analogy would probably be the clinical course of scleromalacia after adjunctive treatment for pterygium, which would suggest a risk for infectious scleritis in later years because these chronic calcific plaques have been shown to harbor bacterial and fungal agents that can lead to endophthalmitis.3

References

1. Rhiu S, Shim J, Kim EK, Chung SK, Lee JS, Lee JB, Seo KY. Complications of cosmetic wide conjunctivectomy combined with postsurgical mitomycin C application. Cornea. 2012;31:245-252.
2. Karalezli A, Kucukerdonmez C, Borazan M, Akova YA. Successful treatment of necrotizing scleritis after conjunctival autografting for pterygium with amniotic membrane transplantation. Orbit. 2010;29:88-90.
3. Moriarty AP, Crawford GJ, McAllister IL, Constable IJ. Severe corneoscleral infection; a complication of beta irradiation scleral necrosis following pterygium excision. Arch Ophthalmol. 1993;111:947-951.
© 2014 by Lippincott Williams & Wilkins, Inc.