Rehnuma, Rahman, Kadir, Ahmed, and Huq: Diffuse surgically induced scleritis following strabismus surgery: A case report


Scleritis, inflammation of the sclera, is a typically painful, destructive condition. It is a potential risk of permanent ocular structural damage with visual compromise. Scleritis can be immune mediated or can be associated with infection, trauma, surgery, and medications.

The surgically induced necrotizing scleritis (SINS) is a well‑recognized entity. It is reported following cataract surgery,1, 2, 3, 4, 5, 6, 7, 8, 9, 10 Penetrating keratoplasty,11 strabismus surgery for thyroid ophthal­myopathy12 and cataract surgery complicated by infection.13 Surgically induced diffuse scleritis (SIDS) is less well recognised.

Though not always, but in some cases, it has been reported to occur in excessive conjunctival manipulation and episcleral vessel cautery, such as pterygium or extracapsular cataract extraction surgery. Although infrequent, the onset of features of necrotizing scleritis in a case of initially nonnecrotizing disease can occur in up to 15% of cases, prompting further investigation and adequate therapy. The necrotizing process usually starts at the site of surgery and extends outwards, but tends to remain localized to one sector. Studies show that up to 90% of such cases may have an undiagnosed systemic autoimmune condition. Surgically induced diffuse scleritis is also a rare iatrogenic entity in eyes undergoing multiple ocular surgeries.

Case Report

A 30-year-old female patient underwent an uneventful strabismus surgery at her right eye for alternate exotropia of 50 Prism Diopter (Fig. 1) with dominant left eye. Six weeks later after the surgery, she developed severe pain with redness of her right eye. Ocular examination showed multifocal non- necrotizing scleritis with prominent tortuous and dilated scleral vessels involving inferior and nasal aspect of the sclera. There was no scleral thinning. Posterior segment showed slightly tortuous blood vessels but B-scan revealed normal choroidal thickness with no sign of posterior scleritis.

Figure 1

Alternate Exotropia of 50 prism diopter of right eye with dominating left eye.

All the relevant examinations were done and routine laboratory investigations were normal. We started topical steroid and oral NSAID. After one week, we followed up the patient. There was slow improvement but not as much as we expected. So, we started oral steroid. Two weeks after, again she had a follow up visit. This time, scleritis involved more area and became diffuse scleritis, but non- necrotizing variety with some area of scleral thinning (Fig. 2). This time, we started immunomodulatory therapy with oral Methotrexate and Folic acid supplementation.

Figure 2

Anterior segment photograph of both eyes showing conjunctival injection, inferior scleral vessel dilatation and tortuosity with temporal thinning.


Surgically induced scleritis occurs more frequently in women with underlying systemic autoimmune disease and after multiple ocular procedures. 14, 15 In our case, all the routine examination and relevant laboratory work up were done which revealed no systemic autoimmune disease. The surgery was done for 50 PD exotropia which was an uneventful procedure.

There is a paucity of literatures describing the diffuse non- necrotizing variety of scleritis following a surgery. Most of the reports described surgically induced necrotizing scleritis. In this case report, we found this patient to have multifocal scleritis in the area of surgery and distant from the area of surgery. Later on, the scleritis turned into diffuse variety, but yet non- necrotizing. Immunomodulatory therapy started to halt the progression to necrotizing variety.

Akbari MR et al described a case of surgically induced necrotizing variety of scleritis following strabismus surgery which initially responded to oral steroid and azathioprine. But three weeks after complete recovery, the patient returned with recurrence with more area of involvement. 16 Till date, we found our patient responds well with oral Azathioprine and no further area of involvement.

Tze Lai et al reported a case where surgically induced necrotizing scleritis developed 48 years after strabismus surgery. 17 In our case, this developed approximately 6 weeks after the surgery.


To our knowledge, this is the first documented case of surgically induced non- necrotizing scleritis following an uneventful strabismus surgery. This report highlights that, scleritis can develop of any variety, any time and without an association of systemic disease after surgery. It seems that, careful monitoring, long course of adequate and appropriate treatment may control the disease process and medications should be carefully tapered.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Criteria for inclusion in the authors’/ contributors’ list

RR, SMUK, ZR- designed the Study, procured the sample and performed the experiments, interpreted the results, RR -wrote the first draft of the manuscript with information from all co-authors; SMUK, SA, NH- critical appraisal of the manuscript; All authors reviewed and approved the final version of the manuscript before submission.

Source of Funding


Conflicts of interest

There are no conflicts of interest.



A Lyne Lloyd-Jones D Necrotizing scleritis after ocular surgeryTrans Ophthalmol Soc UK1979991469


S E Bloomfield C G Becker C L Christian J S Nauheim Bilateral necrotising scleritis with marginal corneal ulceration after cataract surgery in a patient with vasculitis.Br J Ophthalmol 1980643170410.1136/bjo.64.3.170


SM Salamon BJ Mondino GW Zaidman Peripheral Corneal Ulcers, Conjunctival Ulcers, and Scleritis after Cataract SurgeryAm J Ophthalmol 1982933334710.1016/0002-9394(82)90535-9


E Gregersen J S Jorgensen Necrotising sclerokeratitis fol­ lowing cataract extractionKlin Monatsbl Augenheilkd 19881936424


S Behrendt C Eckardt Postoperative necrotising scleroker­ atitisKlin Monatsbl Augenheilkd19901975035


M Sainz-De-La-Maza C S Foster Necrotising scleritis after ocular surgery: a clinicopathologic studyOphthalmology19919817206


G Salacz Postoperative necrotizing sclerokeratitisDoc OphthalmoI19928021677010.1007/bf00161242


S Haider Spontaneous extrusion of an intraocular lens implantJ Cataract Refract Surg19921852930


DB Glasser J Bellor Necrotizing Scleritis of Scleral Flaps After Transscleral Suture Fixation of an Intraocular LensAm J Ophthalmol 199211355293210.1016/s0002-9394(14)74724-5


E O'Donoghue S Lightman S Tuft P Watson Surgically induced necrotising sclerokeratitis (SINS)--precipitating factors and response to treatment.Br J Ophthalmol1992761172110.1136/bjo.76.1.17


CJ Lyons JKG Dart WA Aclimandos S Lightman RJ Buckley Sclerokeratitis after Keratoplasty in AtopyOphthalmology19909767293310.1016/s0161-6420(90)32523-x


LK Kaufman ER Folk MT Miller HH Tessler Necrotizing Scleritis Following Strabismus Surgery for Thyroid OphthalmopathyJ Pediatr Ophthalmol Strabismus1989265236810.3928/0191-3913-19890901-07


A N Carlson G N Foulks J R Perfect J H Kim Fungal scler­ itis after cataract surgery: successful outcome using itraco­ nazoleCornea1992II1514


E O'Donoghue S Lightman S Tuft P Watson Surgically induced necrotising sclerokeratitis (SINS)--precipitating factors and response to treatment.Br J Ophthalmol1992761172110.1136/bjo.76.1.17


MS de la Maza CS Foster Necrotizing Scleritis after Ocular SurgeryOphthalmology199198111720610.1016/s0161-6420(91)32062-1


MR Akbari M Mohebbi M Johari A Mirmohammadsadeghi A Mahmoudi Multifocal Surgically Induced Necrotizing Scleritis Following Strabismus Surgery: A Case ReportStrabismus2016243101510.1080/09273972.2016.1205104


T Lai I Leibovitch R Zadeh M Chehade D Tamblyn D Selva Surgically Induced Necrotizing Scleritis Occurring 48 Years After Strabismus SurgeryJ Pediatr Ophthalmol Strabismus2005423180210.3928/01913913-20050501-07


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Received : 04-06-2021

Accepted : 15-06-2021

Available online : 24-07-2021

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