Immunologic and clinical evaluation of postsurgical necrotizing sclerocorneal ulceration

To perform a clinical, laboratory and pathologic evaluation in patients who had developed a postsurgical necrotizing sclerocorneal ulceration to detect a serious associated autoimmune disorder and to treat the ocular disease early.

Nine patients with postsurgical necrotizing sclerocorneal ulceration after uneventful cataract extraction were studied by means of immunohistochemical techniques on conjunctival resections, immunologic serologic studies, and rheumatologic evaluation. Nine healthy subjects who underwent uneventful cataract surgery were used as controls.

The pathologic studies showed a local immunoglobulin M (IgM) and IgG deposition, increased human leukocyte antigen (HLA-DR) expression, and a significant T-helper cell participation in conjunctival biopsies in the most severe ulcerations, which were detected in four patients with underlying autoimmune systemic disorder (rheumatoid arthritis, 45%) and only a macrophagic infiltration in the mildest ulcers in patients (55%) without immune disorders. Serologic features included high titers of rheumatoid factor in the four (45%) patients with rheumatoid arthritis, nonspecific serologic immune alteration in three (33%) patients, and were unremarkable in two (22%) patients. The medical and immunologic evaluations were negative in the control cases. Topically administered cyclosporin A healed the ocular disease.

A surgically induced local autoimmune reaction could occur in the incision area in patients with systemic vasculitic disease. There was no underlying systemic disorder in the mildest ulcers, and these ulcers could be due to a defect in the surgical technique. Our results suggest the need for a detailed systemic evaluation in patients with severe postsurgical necrotizing ulceration. Early diagnosis and aggressive medical treatment of the ocular disorder improves the visual outcome.