Scleritis Associated with Scleral Buckling Requires Aggressive Treatment

Managing inflammation of surgically induced scleritis following retinal surgery using NSAIDs, immunosuppressive therapy and surgical intervention provides favorable visual outcomes. Photo: Nimest Patel, MD/Bascom Palmer. Click image to enlarge. While surgically induced scleritis following retinal surgery is rare, its clinical features and outcomes aren’t well known. In a recent study, researchers investigated surgically induced scleritis following pars plana vitrectomy (PPV) or scleral buckling surgery and found that the condition associated with scleral buckling appears to require more aggressive medical and surgical intervention than scleritis following PPV. The findings were reported in Eye.This retrospective case series included all cases of surgically induced scleritis following PPV or scleral buckling surgery at London’s Moorfields Eye Hospital between September 2012 and June 2024. Those with a previous history of scleritis were excluded.A total of 40 cases were identified: 23 post-PPV and 17 post-scleral buckling surgery. The estimated annual incidence was five cases per 100,000 PPV and 45 cases per 100,000 scleral buckling surgery. Scleritis was non-necrotizing in 62.5% cases and developed following multiple retinal surgeries in 45% cases. Post-PPV scleritis presented earlier (3.6 weeks vs. 33.4 weeks) but appeared less likely to be necrotizing (26% vs. 47%) than scleral buckling surgery scleritis. For help in differentiating scleritis from episcleritis, see this CE feature. Necrotizing scleritis may be more common following scleral buckling surgery than PPV because scleral buckling surgery is primarily an extraocular procedure with most of the surgical maneuvers carried out at the level of sclera, the authors noted. The scleral explant was removed in 59% cases of scleral buckling surgery scleritis. A scleral patch graft was applied in 5% of cases.“Given the improvement in scleritis following removal of scleral explant, it is thought that scleral buckling, especially encirclement, induces scleritis via mechanical compression and ischemia,” the authors wrote in their paper on their work. Previous studies show that ischemia alone appears insufficient and other factors such as abnormal response to surgical trauma, increased collagenase action and immune complex deposition may be involved.Indications for PPV were retinal detachment (nine cases, 39%), removal of silicone oil post-retinal detachment repair (six cases, 26%), scleral-fixated intraocular lens implantation (three cases, 13%), full-thickness macula hole (two cases, 8.7%), macula proliferative vitreoretinopathy (one case, 4.3%), iris-fixated intraocular lens implantation (one case, 4.3%) and intraocular foreign body removal (one case, 4.3%).In the post-PPV group, oral NSAIDs in combination with topical steroids and/or NSAIDs were sufficient for post-PPV anterior non-necrotizing scleritis cases. Flurbiprofen was most used with a median daily dose of 150mg over two weeks.Compared to post-PPV cases, scleritis following scleral buckling surgery presented later, but was more likely to require systemic steroids, immunomodulatory therapy or surgical intervention.Oral NSAIDs were given in the majority of cases—33 (82.5%); flurbiprofen was most used with a median daily dose of 300mg over three weeks in the post-scleral buckling surgery scleritis group. Systemic steroids or immunomodulatory therapy were used more frequently in scleral buckling surgery scleritis than post-PPV scleritis (29.4% vs. 8.7%). Oral prednisolone was successfully tapered over six to nine weeks in three cases.At 15 months’ follow-up, the final BCVA in the post-PPV group was 0.54, and the median change in BCVA was -0.18, indicating most eyes maintain or gain vision with treatment. Vision loss of at least one line was seen in five eyes, and four cases had one episode of scleritis recurrence.At eight months follow-up in the scleral buckling surgery group, the final BCVA was 0.48, with scleritis recurring in five cases. The median change in BCVA was 0.00 with the majority of patients maintaining or gaining vision with treatment. Three patients lost at least one line of vision. Click here for the journal source.  Raharja A, Shah N, Ahmed S, et al. Surgically induced scleritis after pars plana vitrectomy or scleral buckling surgery: a 12-year audit. Eye. April 16, 2025. [Epub ahead of print.]