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Secondary glaucoma due to chronic scleritis: trabeculectomy in scleromalacia: a case report

Subjects

Sir,

Secondary open-angle glaucoma is frequently refractory and difficult to manage.1

Glaucoma is uncommon in scleritis, but may develop due to permanent damage to the trabecular meshwork even in quiescent scleritis.2 Posterior scleritis has been reported to cause angle-closure glaucoma.3, 4, 5, 6 Other mechanisms include secondary steroid-induced glaucoma, peripheral anterior synechiae, and angle neovascularisation.

Scleritis has been reported following surgical trabeculectomy.7

Case report

A 68-year-old Caucasian patient had been followed up for 14 years with recurrent bilateral sectoral anterior non-necrotising scleritis in the absence of underlying systemic disease.

The intraocular pressure (IOP) had been controlled with topical g.Timolol 0.5% BD for the previous 5 years. Five months prior to surgery, IOP increased to 30 mm Hg. Despite maximal medical treatment (g.Bimatoprost/Timolol (Ganfort), g.Brinzolamide (Azopt), and Acetazolamide SR 250 mg p.o. BD) her IOP remained at 39 mm Hg. This was associated with a cup-disc ratio of 0.85 and predominantly nasal superior and inferior visual field defects (Figure 1).

Figure 1
figure1

Visual fields.

This patient was surgically challenging due to the presence of diffuse scleromalacia (Figures 2 and 3 (arrow C)), with one small island of peri-limbal white sclera supero-temporally. The sclera was too thin posteriorly for a tube or valve.

Figure 2
figure2

Pre-operative scleromalacia in the left eye.

Figure 3
figure3

Post-operative trabeculectomy bleb (Arrow A).

A trabeculectomy with Mitomicin C (0.2 mg/ml for 1 min) was performed without complication (Figures 3 (arrow A) and 4), using two releasable 10/0 nylon sutures to the scleral flap. Oral Prednisolone 40 mg/30/20/10 weekly taper, g.Prednisolone 1.0% 2 hourly, and g.Chloramphenicol q.d.s. were prescribed post-operatively. Subsequent IOP decreased to 6 mm Hg, and VA was 0.30. No recurrence of scleritis has occurred since the surgery, and the patient continues to use g.Prednisolone 1% o.d. 4 months post-operatively.

Figure 4
figure4

Post-operative trabeculectomy bleb (Arrow A).

Comment

This patient’s surgery was successful despite significant challenges and a known risk of scleritis resulting from the procedure itself. Oral Prednisolone was prescribed post-operatively, which was key in preventing the recurrence of scleritis in this patient.

Releasable sutures were used (Figure 3 (arrow B)), ensuring a low risk of hypotony immediately pre-operatively. The alternative of laser suture lysis would carry an increased risk of scleral perforation with such thin sclera.

Careful surgical planning, with judicious use of corticosteroids, can result in excellent surgical outcomes in patients with scleritis and secondary glaucoma.

References

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Correspondence to W H Dean.

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Dean, W., Turner, S. & McNaught, A. Secondary glaucoma due to chronic scleritis: trabeculectomy in scleromalacia: a case report. Eye 28, 104–106 (2014). https://doi.org/10.1038/eye.2013.215

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