CASE HISTORY
A 3-year-old male patient presented to our ophthalmology department with
progressive visual deterioration from last 2 years, and following
complete ophthalmic and systemic examination, the patient was diagnosed
as a case of congenital bilateral cataract. The laboratory findings for
this 3-year-old child included complete blood count, blood glucose,
serum phosphate, calcium, serum PTH, and ALP were within the normal
range for age. Additionally, liver function tests (LFTs), renal function
tests (RFTs), and screening for galactosemia were all normal. TORCH
screening was also negative. Hence the case was a bilateral congenital
cataract.
He was listed for bilateral cataract surgery under general anaesthesia.
Surgery was successfully performed with foldable intraocular lens (IOL)
implantation. Intraoperatively, an AST of triamcinolone acetonide 20 mg
was given for control of postoperative inflammation.
The postoperative course was uncomplicated, with the patient being
discharged on topical steroids (dexamethasone, 2-hourly) and topical
antibiotics (tobramycin, 4 hourly).
However, towards the end of the first week after the surgery, the
patient developed localized conjunctival necrosis and scleral thinning
in both eyes, which were more prominent in the supronasal quadrants (as
seen in figure-1). There was conjunctival ischemia with overlying
necrotic tissue and a dull scleral appearance with the presence of early
signs of scleral necrosis. The necrotic region was located over the site
of AST injection which increased the suspicion of an isolated drug
reaction.
Figure 1 demonstrates the initial presentation with regions of
conjunctival necrosis and scleral involvement in both supronasal
quadrants eyes. There was no intraocular inflammation, infection, or
hypotony. The patient had no past medical history of autoimmune disease,
systemic vasculitis, or past ocular surgery, so the reaction to the
triamcinolone injection was the most likely etiology of the necrosis. A
conservative strategy was first implemented, involving topical
lubrication, antibiotics, and corticosteroids. During the subsequent
three weeks, the conjunctival necrosis extended with localized scleral
exposure but without perforation and anterior chamber reaction or uveal
prolapse.
At this time, surgery was contemplated to excise the triamcinolone
deposits, which were thought to be causing persistent scleral toxicity.
Under local anesthesia, a gentle debridement of necrotic tissue and
scraping of residual triamcinolone was performed. The defect
unexpectedly was not that big, and the scleral bed was not destroyed,
with no urgent requirement for grafting.
Postoperatively, the patient was observed closely, and there was notable
improvement within the subsequent few weeks. Figure-2, demonstrates the
ocular surface which has healed with regeneration of conjunctival tissue
and resolution of the necrotic zone. The integrity of the sclera was
maintained, and the vision of the patient remained stable without
evidence of recurrence or inflammation.
DIFFERENTIAL DIAGNOSIS
In a 3-year-old child, scleritis is rare, and other conditions can mimic
its presentation. The differential diagnosis includes but many are not
limited to the following.
Ocular tuberculosis. Investigations were non-contributory to aid the
diagnosis of ocular tuberculosis since there were no systemic
manifestations.
Juvenile Idiopathic Arthritis (JIA)-associated uveitis – Can present
with red eye and anterior segment inflammation. There was no history of
joint disease.
Sarcoidosis – Rare in young children and also systemic and ocular
findings were insignificant to support the diagnosis.
Episcleritis – Less painful, sectoral redness, usually self-limiting.
Typical findings of Episcleritis were not noticed in this patient and
the mentioned findings are supportive of drug induced necrosis.
Traumatic scleritis. There was no history of trauma or foreign body.
Wegener’s granulomatosis (GPA) – Necrotizing scleritis with systemic
vasculitis signs were not present and Anti- neutrophilic cytoplasmic
antibody test was negative.
Such conditions must be carefully ruled out before making a diagnosis of
conjunctival and scleral necrosis following the said intervention.