Case Report: Subconjunctival Triamcinolone Acetate-associated Scleral Necrosis: Is It Really Obsolete?

SIGNIFICANCE: Recent studies have established the safety of subconjunctival steroids for anterior scleritis, refuting scleral necrosis as a potential complication. However, presently, we report a rare case of scleral necrosis associated with subconjunctival triamcinolone acetate. PURPOSE: The purpose of this study was to report a case of scleral necrosis after subconjunctival triamcinolone acetate administration for nonresponsive anterior nodular scleritis. CASE REPORT: A 45-year-old man diagnosed with nodular anterior scleritis was administered subconjunctival triamcinolone acetate (4 mg) adjacent to the nodule after noting nonresponse for 4 months. Worsening of congestion was noted 3 weeks after the injection. Slit-lamp examination revealed diffuse congestion, 10 clock hours of anterior scleral necrosis, superior whitish depot of subconjunctival triamcinolone acetate, anterior segment flare, and few posterior synechiae. Ultrasound biomicroscopic imaging and contrast-enhanced computerized tomography showed a localized outpouching of sclera and buckling of anterior scleral wall superiorly. The result of the comprehensive blood profile and systemic evaluation undertaken to rule out any underlying autoimmune disorders and herpes zoster ophthalmicus was found negative. A diagnosis of subconjunctival triamcinolone acetate-associated scleral necrosis was made, and the patient was managed conservatively. Gradual improvement with dissolution of subconjunctival triamcinolone acetate and no recurrences till 2 years of follow-up were noted. CONCLUSIONS: Scleral necrosis is a potential complication of subconjunctival triamcinolone acetate. Judicious and cautious use of subconjunctival triamcinolone acetate is advocated for nonresolving anterior scleritis.

Inverse centripetal dissection: A rescue technique for mis-dissected lenticule during SMILE.

Management of mis-dissected lenticule during Small-incision lenticule extraction (SMILE) is technically challenging and might be experienced more by novice surgeons especially in eyes with low refractive errors and thin lenticules. Presently, we describe a rescue method of inverse centripetal dissection (ICD) to manage mis-dissected lenticules. In this technique, after inadvertent dissection of posterior plane prior to anterior plane, the double-ended SMILE dissector is rotated along its shaft axis clockwise from the left upper margin of the mis-dissected lenticule to form an inversely folded lenticule which is then subsequently dissected centripetally till midline. This is then extracted by performing lenticulorrhexis with a pair of microforceps. We performed this technique in 10 eyes of 10 patients and the lenticule extraction was accomplished successfully in all eyes. At six months follow-up, the uncorrected visual acuity was 20/20 with a clear interface in all eyes. The ICD approach might serve as a useful rescue technique for managing mis-dissected lenticules.

Optic shrinkage and retraction in opacified hydrophilic acrylic intraocular lens: an anterior segment optical CT-based observation.

Intraocular lens (IOL) opacification is a rare phenomenon noted with hydrophilic acrylic IOLs. We report a case of advanced IOL opacification appreciated on anterior segment optical CT (ASOCT)as a shrunken biconcave optic retracted away from the posterior capsule (PC), unlike the other eye which had a clear biconvex IOL of similar material abutting the PC. After IOL exchange, the affected eye was noted to have more folds and Elschnig's pearls on the PC when compared with the other eye. Our case points towards rare IOL changes seen in advanced cases of opacification, their association with posterior capsular changes and the aid of ASOCT as a non-invasive tool in diagnosing them correctly.