Scientific Online Resource System

Bulgarian Review of Ophthalmology

Surgically induced necrotizing scleritis

Petya Todorova, Elena Mermeklieva, Valentin Hristozov


Aim: The aim of this article is to present a clinical case of a postoperative complication of pterygium surgery—surgically induced necrotizing scleritis with corneal ulcer, and to propose a diagnostic and therapeutic algorithm.

Materials and Methods: The case refers to a woman with pterygium who underwent a thorough preoperative ophthalmological examination. We examined: visual acuity, tonometry, biomicroscopy, funduscopy, corneal topography, and performed frontal photography of the anterior segment and nasal abduction of the eye bulb. A technique of simple closure of the conjunctiva without antiproliferative agent was used. Postoperatively, the patient was followed up on the first and tenth days, as well as the first, second, and third months. The accompanying documentation was analyzed—video documentation, paraclinical examinatiоn, B-scan, and photo documentation.

Results: On the tenth postoperative day, we found corneal and scleral ulcer. On the 28th postoperative day, a development in the condition was observed—an increase in the area and depth, mainly of the scleral ulcer. A diagnosis of necrotizing scleritis was made. An effective treatment was done, with the so-called soft steroid—loteprednol etabonate, and epithelializing eye drops and gels. It resulted in halting the necrosis and preventing the risk of bulbar perforation.

Conclusion: Although a rare complication after pterygium surgery, necrotizing scleritis should be considered in any surgery and appropriate measures should be taken to prevent this sight-threatening postsurgical complication. 


pterygium; scleritis; corneal ulcer; surgically induced necrotizing scleritis

Full Text


Watson PG, Hayreh SS, Awdry PN. Episcleritis and scleritis. Brit J Ophthalmol. 1968;52 (3):278–9. doi: 10.1136/bjo.52.3.278.

Daniel DJ, Sobol EK, Gritz DC. Treatment and management of scleral disorders. Surv Ophthalmol. 2016;61(6):702-17. doi: 10.1016/j.survophthal.2016.06.002.

Wakefield D, Di Girolamo N, Thurau S, Wildner G, McCluskey P. Scleritis: immunopathogenesis and molecular basis for therapy. Prog Retin Eye Res. 2013;35:44–62. doi: 10.1016/j.preteyeres.2013.02.004.

Doshi RR, Harocopos GJ, Schwab IR, Cunningham Jr ET. The spectrum of postoperative scleral necrosis. Surv Ophthalmol. 2013;58(6):620–33. doi: 10.1016/j.survophthal.2012.11.002.

O’Donoghue E, Lightman S, Tuft S, Watson P. Surgically induced necrotising sclerokeratitis (SINS)-precipitating factors and response to treatment. Br J Ophthalmol. 1992;76(1):17-21. doi: 10.1136/bjo.76.1.17.

Ilieva A, Zlatarova Z. Surgical treatment of pterygium with conjunctival autograft. Bulg Rev Ophthalmology. 2018;62(2):44-9. doi: 10.14748/bro.v0i2.5068.

Gaonker T, Yadav A, Rastogi A, Bansal P, Jeng BH (editor). Surgically Induced Necrotizing Scleritis: An Overview. EyeNet Magazine. 2021;33-35.

Riono WP, Hidayat AA, Rao NA. Scleritis: a clinicopathologic study of 55 cases. Ophthalmology. 1999;106:1328–33. doi: 10.1016/S0161-6420(99)00719-8.

Riley GP, Harrall RL, Watson PG, Cawston TE, Hazleman BL. Collagenase (MMP1) and TIMP-1 in destructive corneal disease associated with rheumatoid arthritis. Eye. 1995;9 (6):703–18. doi: 10.1038/eye.1995.182.

Bodor N, Buchwald P. Ophthalmic drug design based on the metabolic activity of the eye: soft drugs and chemical delivery systems. AAPS J. 2005;7(4):E820–33. doi: 10.1208/aapsj070479.

Sultan D, Alnema O, Sultan MN, Zahlouk N, Kayyalia A. A case of resistant scleral thinning following uneventful pterygium surgery: A case report and a literature review. Int J Surg Case Rep. 2022;95(1):107223. doi: 10.1016/j.ijscr.2022.107223.

Garcia-Medina JJ, Del-Rio-Vellosillo М, Zanon-Moreno V, Ortiz-Gomariz A, Morcillo-Guardiola M, Pinazo-Duran MD. Severe scleral dellen as an early complication of pterygium excision with simple conjunctival closure and review of the literature. Arq Bras Oftalmol. 2014;77(3):182-4. doi: 10.5935/0004-2749.20140046.

Chen S, Noonan C. Scleral dellen complicating primary pterygium excision. Eye. 2000;14(Pt 1):100-1. doi: 10.1038/eye.2000.22.

Starck Т, Kenyon KR, Serrano F. Conjunctival autograft for primary and recurrent pterygia: surgical technique and problem management. Cornea. 1991;10(3):196-202. doi: 10.1097/00003226-199105000-00002.

Accorinti M, Gilardi M, Giubilei M, Geronimo DD, Iannetti L. Corneal and scleral dellen after an uneventful pterygium surgery and a febrile episode. Case Rep. Ophthalmol. 2014;5(1):111-5. doi: 10.1159/000362156.

Majumder PD, Ghose A, Chidambaram M, Ganesh SK, Biswas J. Clinical profile of patients with necrotizing scleritis in a tertiary eye care center in Southern India. Ocul Immunol Inflamm. 2018;26:412–6. doi: 10.1080/09273948.2016.1223857.

Tanaka R, Kaburaki T, Ohtomo K, Takamoto M, Komae K, Numaga J, et al. Clinical characteristics and ocular complications of patients with scleritis in Japanese. Jpn J Ophthalmol. 2018;62(4):517–24. doi: 10.1007/s10384-018-0600-y.

Mitra S, Ganesh A, Shenoy R. Scleral dellen complicating primary pterygium excision. Eye. 2000;14 (Pt 6):924-5. doi: 10.1038/eye.2000.263.

Maurice D, Watson PG. The distribution and movement of serum albumin in the cornea. Exp Eye Res. 1965;4(4):355–63. doi: 10.1016/s0014-4835(65)80052-5.

Watson PG, Young RD. Scleral structure, organisation and disease. Exp Eye Res. 2004;78(3):609–23. doi: 10.1016/s0014-4835(03)00212-4.

Watson P, Romano A. The impact of new methods of investigation and treatment on the understanding of the pathology of scleral inflammation. Eye (Lond). 2014;28(8):915–30. doi: 10.1038/eye.2014.110.

Tsai YY, Lin JM, Shy JD. Acute scleral thinning after pterygium excision with intraoperative mitomycin C: a case report of scleral dellen after bare sclera technique and review of the literature. Cornea. 2002;21(2):227-9. doi: 10.1097/00003226-200203000-00022.

Hicks RR, Irvine AR, Spencer WH, Yuhasz Z. Scleral dellen. Arch Ophthalmol. 1975;93(1):88-9. doi: 10.1001/archopht.1975.01010020092020.



Font Size

About The Authors

Petya Todorova
Trakya University

Ophthalmology Department, MHAT "Trakya", Stara Zagora city

Medical Doctor

Elena Mermeklieva
Medical Faculty, Sofia University St. Kliment Ohridski

Department of Ophthalmology, Lozenetz University Hospital, Sofia

Valentin Hristozov
Trakia Hospital, Stara Zagora

Department of Ophthalmology