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.