Successful Ocular Structural Restoration of Aggressive Necrotizing Sclerouveitis Following Pterygium Excision:...

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.

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 weekly rituximab infusions and 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.

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.