Successful ocular structural restoration of aggressive necrotizing sclerouveitis following pterygium excision: infectious, autoimmune, or both?
Year: 2026
Type: article
Abstract: Purpose To report a case of severe refractory surgically induced scleral necrosis (SISN) with pan-uveitis and retinal detachment following pterygium excision, highlighting the challenges in differentiating infectious versus autoimmune mechanisms and demonstrating successful restoration of ocular structure with combined surgical and immunosuppressive therapy in a patient with poor initial prognosis. Observation An 80-year-old man presented one year after pterygium surgery with severe pain, redness, and vision loss in the right eye. Examination revealed nasal necrotizing scleritis with purulent discharge, extensive scleral thinning and uveal exposure, pan-uveitis, serous retinal detachment, and choroidal folds. Co-infection was suspected, and systemic autoimmune predisposition was suggested by p-ANCA positivity and history of cutaneous lupus. The patient underwent urgent scleral debridement and biopsy, along with topical and systemic antibiotics, followed by 8 weekly and then monthly rituximab infusions along with mycophenolate mofetil under steroid taper. After eight cycles of active treatment, scleral inflammation improved significantly, scleral thickness restored, and retinal detachment and subretinal fluid completely resolved. At last follow-up, visual acuity improved from counting fingers to 20/100 with restoration of ocular structural integrity. Conclusion The index case highlights the challenge of distinguishing infection from autoimmunity in SISN. Early debridement, prompt antimicrobial treatment, and immunosuppressive therapy are crucial in the management of SISN. Rituximab infusion is safe and effective for rapidly controlling severe scleral inflammation once infection is ruled out or is under control.
Authors: Cristian de los Santos, David Chanthan, Dalia El-Feky, Gunjan Awatramani, Amir Akhavanrezayat, Alan Sherif, Negin Yavari, David Ni Xu, Aubrey Nguyen, Isaac Sanchez, Osama Elaraby, Jingli Guo, Bin Mo, Ishaan Iyer, Mohammad Rajabi, Azadeh Mobasserian, Anh Ngoc Tram Tran, Yu-Kuei Lee, Gunay Uludag Kirimli, Ngoc Trong Tuong Than, Jia-Horung Hung, Quan Dong Nguyen
Institution: Tanta University
Language: English
Subfield: Ophthalmology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,290
OpenAlex ID: W7222832374
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