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The onset of scleral necrosis after ocular surgery may have catastrophic ocular and systemic consequences. The two most frequent surgeries causing surgically-induced scleral necrosis (SISN) are pterygium excision and cataract extraction. Several pathogenic mechanisms are involved in surgically induced scleral necrosis. All of them are poorly understood. Ocular trauma increasing lytic action of collagenases with subsequent collagen degradation, vascular disruption leading to local ischemia, and immune complex deposition activating the complement system represents some of the events that lead to scleral necrosis. The complex cascade of events involving different pathogenic mechanisms and the patient's abnormal immune response frequently leads to delayed wound healing that predisposes the development of scleral necrosis. The management of SISN ranges from short-term systemic anti-inflammatory drugs to aggressive immunosuppressive therapy and surgical repair. Therefore, before performing any ocular surgery involving the sclera, a thorough ophthalmic and systemic evaluation must be done to identify high-risk patients that may develop SISN., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the role of pars plana vitrectomy-assisted incisional biopsies in the management of choroidal tumors of unclear origin., Design: Retrospective, noncomparative, consecutive interventional case series., Methods: Ten consecutive patients with indeterminate choroidal tumors underwent a standardized three-port pars-plana vitrectomy-assisted subretinal biopsy using a bimanual approach with standard intraocular forceps and a diamond knife. Specimens were fixed in formaldehyde embedded in paraffin and further subjected to histopathological and immunohistochemical analyses., Results: A histologic diagnosis was obtained in all (10 of 10) cases including choroidal melanoma (five of 10), metastasis (two of 10), subretinal hemorrhage (two of 10), and nodular scleritis (one of 10). Five eyes were enucleated as a result of the histologic diagnosis. Three cases of postoperative complications were seen in three patients (newly formed rhegmatogenous retinal detachment, increased serous retinal detachment, and vitreous hemorrhage). No cases of intra- or extraocular tumor spread were detected through follow-up periods ranging from 3 to 29 months., Conclusions: Pars plana vitrectomy-assisted incisional biopsy is a valuable diagnostic procedure for cases of choroidal tumors of unknown origin in selected patients. However, the relatively high frequency of postoperative complications noted in the present study and the potential risk of dissemination of tumor cells underscores the importance of rigorous case selection.

Scleritis is typically a severe painful inflammatory process centered in the sclera that may involve the cornea, adjacent episclera, and underlying uvea; it poses a significant threat to vision. Careful clinical history taking, detailed ocular examination, appropriate investigation for ocular disease with or without underlying systemic disease, and timely intervention with the use of immunosuppressant drugs when necessary, has improved the long-term outcome for patients with this disease.

Purpose: To determine choroidal involvement in posterior scleritis by examining indocyanine green angiographic features., Methods: Indocyanine green angiography was performed according to a standard uveitis angiographic protocol in eight consecutive patients with posterior scleritis. Indocyanine green angiography data were compared to fundus color photographs, red-free photographs, and fluorescein angiography., Results: The principal indocyanine green angiographic feature was diffuse zonal choroidal indocyanine green hyperfluorescence in the intermediate (+/-10 minutes) and late (+/-40 minutes) phases of angiography present in all eight patients who regressed in response to anti-inflammatory therapy. In four patients (two with massive subretinal exudation), additional fluorescing pinpoints were present in the zonal hyperfluorescent areas. Additional features included irregular delayed choroidal perfusion (five of eight patients)--irregularly distributed dark dots that were present up to the intermediate phase and becoming isofluorescent in the late phase that gave a mottled aspect to the choroid--and enlargement of draining choroidal veins. In bilateral patients, clinical features and indocyanine green angiography signs were roughly symmetric., Conclusions: In posterior scleritis, indocyanine green angiography allowed us to identify areas of choroidal hyperfluorescence, possibly indicating areas of maximal inflammatory activity, and demonstrated regression of hyperfluorescence in response to therapy. Indocyanine green angiography was useful in assessing the extent of choroidal involvement and will probably serve as one of the follow-up parameters for disease evolution and response to therapy.

We treated a healthy soft contact lens wearer who developed Acanthamoeba sclerokeratitis in the left eye. The patient had severe pain and ring-shaped subepithelial infiltrates. The keratitis progressed and scleral nodules developed despite aggressive treatment with topical clotrimazole, dibromopropamidine isethionate, and corticosteroids. Corneal transplantation and cryotherapy were performed. The corneal button demonstrated Acanthamoeba cysts. Cultures of biopsy specimens taken from two different scleral nodules at two separate times were positive for Acanthamoeba. The disease progressed despite a second corneal graft and the addition of polyhexamethylene biguanide eyedrops. Enucleation of the left eye was required. Histopathologic examination of the specimen documented an Acanthamoeba cyst associated with a granulomatous inflammatory response deep in the sclera. Acanthamoeba scleritis may be associated with a poor prognosis, even with intensive medical and surgical treatment.

A 23-year-old male presented with bilateral sclerokeratitis. He reported recent bronchitis, sinusitis, dyspnea on exertion, hemoptysis, arthralgias and myalgias. Wegener's granulomatosis was diagnosed by a positive antineutrophil cytoplasmic autoantibody (ANCA) test and a nasal and subglotic biopsy showing granulomatous inflammation. Treatment with cyclophosphamide, systemic corticosteroids and trimethoprim/sulfamethoxazole resulted in resolution of the sclerokeratitis and remission of the disease.

Pterygium excision was complicated by bacterial corneoscleritis and endophthalmitis in two patients, one who had received postoperative beta irradiation and the other topical thiotepa. These complications followed surgery by two and six weeks. Causative organisms were Streptococcus pneumoniae and Pseudomonas aeruginosa, respectively. Despite aggressive therapy, visual outcome was poor in both cases. These cases demonstrate that, although infrequent, complications of pterygium excision can be destructive and visually disabling.