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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 2  |  Issue : 1  |  Page : 30

Autologous fascia lata grafting in scleromalacia perforans


1 Department of Ophthalmology, Edgardo Regalito Martins Hospital, Lima-Perú, Colombia
2 Department of Ophthalmology, Edgardo Regalito Martins Hospital, Lima-Perú; University del Bosque, Bogotá, Colombia

Date of Submission25-Jun-2020
Date of Decision25-Jun-2020
Date of Acceptance09-Jul-2020
Date of Web Publication20-Oct-2020

Correspondence Address:
Dr. Karin F A. Caro
Av. San Luis 2715 Dpto 302 San Borja, Lima
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PAJO.PAJO_30_20

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  Abstract 


Ocular perforating is the most dreaded scenario to confront in patients with scleromalacia perforans. Despite its low prevalence, the progression of scleral necrosis to exposed uvea represents one of the ophthalmic emergencies with a high risk of loss of ocular content whose surgical treatment is performed autologous or heterologous tissue patches. This study describes six patients referred to the ophthalmology service of the Edgardo Rebagliati Martins National Hospital in Lima with a clinic history of autoimmune diseases and scleromalacia perforans >10 mm size, treated with autologous fascia lata grafting in addition to topical and systemic immunosuppressive treatment.

Keywords: Case report, fascia lata, perforans scleromalacia


How to cite this article:
A. Caro KF, C. Chávez LG, Sanchez CP, Archila EA. Autologous fascia lata grafting in scleromalacia perforans. Pan Am J Ophthalmol 2020;2:30

How to cite this URL:
A. Caro KF, C. Chávez LG, Sanchez CP, Archila EA. Autologous fascia lata grafting in scleromalacia perforans. Pan Am J Ophthalmol [serial online] 2020 [cited 2020 Nov 27];2:30. Available from: https://www.thepajo.org/text.asp?2020/2/1/30/298635




  Introduction Top


Perforans scleromalacia (PS) is only 4% of scleritis. It starts with subconjunctival yellow or gray nodules that can progress to scleral necrosis and exposed uvea (perforation is infrequent). It is associated with autoimmune diseases such as rheumatoid arthritis (RA), granulomatosis with polyangiitis (GPA), and others.[1],[2]

Treatment can be medical and surgical. Surgical treatment is indicated in exposed uvea to preserve globe integrity with the scleral, dermis, fascia lata, periosteum, aortic tissue, cornea, cartilage, or amniotic membrane patch grafting.[3]

This study presents six patients referred to ophthalmology service at the Edgardo Rebagliati Martins National Hospital in Lima, Peru, with clinic history of immunological diseases and PS >10 mm size, treated with autologous fascia lata grafting, also systemic immunosuppressive therapy and topical treatment with 0.03% ophthalmic tacrolimus.


  Case Reports Top


Case 1

A 65-year-old woman with hypertension, chronic renal disease on peritoneal hemodialysis, pulmonary fibrosis, postsurgery for pterygium in both eyes (OU) and in topical treatment for chronic glaucoma was referred to our service with scleromalacia in the left eye (OS). Corrected distance visual acuity (CDVA) right eye (OD): 0.8 OI: 0.3; AO 0.6 with pinhole (PH). Intraocular pressure (IOP) OD: 27 mmHg, OS: 35 mmHg. In OS slit lamp, nasal scleral defect with exposed uvea. Studies were carried out, and GPA was diagnosed. Systemic immunosuppressive treatment was started, and glaucoma treatment was regulated. A corneal patch and multilayer amniotic membrane were placed, which necrotized after 2 months. One week later, an autologous fascia lata grafting was performed; it was properly integrated into the scleral wall [Figure 1]. At 6 months, the uncorrected distance visual acuity (VA) was 0.4, and the IOP was 20 mmHg OS. The patient died 2 years later due to complications of her underlying disease.
Figure 1: a) Left, the yellow arrow shows preoperative left eye nasal uveal exposure. b)Right, the green arrow shows the fascia lata graft

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Case 2

A 68-year-old woman postpterygium nasal excision with mitomycin C OS 1 year ago, sclerocorneal grafting surgery two times for SP in OS. was referred to our service with the diagnosis of scleromalacia, with exposed nasal uvea. CDVA OD: 0.9 OS: 0.3 and 0.5 PH. IOP OD: 13 mmHg OS: 13 mmHg. In OS slit lamp, nasal scleral thinning with exposed uvea, posterior synechiae, and lens with nuclear opacity. Negative laboratory tests for systemic diseases. At the surgical moment, few fibers of rectus medial OS muscle were evident. Autologous fascia lata grafting was performed [Figure 2]. The graft was properly integrated. VA remains. Controls until 6 months, then the patient did not return.
Figure 2: a) Left, the blue arrow shows preoperative left eye nasal uveal exposure. b) Right, the green arrow shows the fascia lata graft

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Case 3

A 57-year-old woman with RA 7 years ago and apparent scleral tumor excision OS. Referred by corneal perforation OS. Slit-lamp shows superior nasal corneoscleral perforation of OS and atalamia. The diagnosis of active RA was confirmed, and Infliximab was started. Surgery was performed with a corneal scleral ring graft. One week later, she presented another inferior nasal scleral perforation of OS, and autologous fascia lata graft surgery was decided [Figure 3]. After 3 years of follow up, tje patient presented with adequate graft adherence.
Figure 3: a) Left, preoperative left eye superior corneo-scleral perforations and atalamia. b) Right, the green arrow shows the fascia lata graft covered by the conjunctiva

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Case 4

A 42-year-old male with GPA referred for extensive scleromalacia of OS. On examination, OS with extensive scleral thinning in the temporal zone with exposed uvea, the lens with posterior subcapsular opacity, and exudative retinal detachment. GPA activity was checked. A fascia lata grafting was performed in the temporary zone of OS [Figure 4]. The graft was well apposed with UDAV 0.5 in the OS. Patient was followed up for 2 years.
Figure 4: a) Left, yellow arrow shows preoperative left eye upper temporal uveal exposure. b) right, blue arrow shows the fascia lata graft covered by the conjunctiva

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Case 5

A 67-year-old woman with irregular treatment of RA, history of cataract surgery and OU penetrating keratoplasty. Referred by scleromalacia with perforation in the nasal region of OS. On examination, corneal and nasal scleral perforations of OS. AR activity was checked. Corneal grafting was performed, which became necrotic at 2 months. After that, a fascia lata grafting was performed. Globe integrity was preserved with 1 year of follow-up.

Case 6

A 50-year-old female with GPA referred for extensive upper sclera OD. On examination, on extensive scleromalacia, the term of the OD scleral defect was not visualized. GAP activity was checked. Fascia lata grafting was performed but could not be properly anchored due to the lack of visualization of the term of the defect [Figure 5]. The graft was lost after 2 months in its entirety.
Figure 5: a) Left, yellow arrow shows preoperative right superior extensive scleral thinning. right, b) green arrow shows the fascia lata graft covered by the conjunctiva

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The surgical acts were performed under general anesthesia with a duration of approximately 3 h. The fascia lata graft was obtained from the same patient at the same surgical time with the collaboration of a plastic surgeon or orthopedic surgeon, after having obtained the graft it was kept in the balanced saline solution until it was placed.

Fascia lata eye patch

For better visualization of the area to be treated, put a repair point with vicryl 6/0 in the limbus for traction, then conjunctival peritomy adjacent to the area to be treated, dissect until finding adequate scleral tissue to suture. Measure the size of the defect and then trim the shape to the graft of fascia lata. Suture the graft with 10/0 nylon to the sclera [Figure 6] and [Figure 7]. Dissect the adjacent tenon to cover the graft and anchor it to areas without alteration. Cover the graft with the conjunctiva and tenon, make relaxing incisions in both. If the conjunctiva is insufficient to cover the defect, an amniotic membrane can be used (suture with 10/0 nylon).
Figure 6: Anteroposterior and lateral view: Above, prolapsed uvea. Center, dissection around the defect. Below, fascia lata restoring the ocular anatomy. (A) ciliary body and choroid. (B) Thick sclera. (C) Fascia lata

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Figure 7: Placing the fascia lata graft over the defect

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  Discussion Top


Perforating scleromalacia is a degeneration of the sclera due to autoimmune damage of the episcleral and scleral vessels (type III hypersensitivity) of long evolution.[3] Initially asymptomatic with slow progression. Scleral thinning causes choroidal herniation, protected or not with conjunctiva. As described by der Hoeve in 1934, Dr Paufique et al. described a surgical treatment using scleral grafts.[4] In 1955, Armstrong and McGovern described the use of fascia lata for complex cases of scleromalacia[5], a technique used thereafter by other authors.[6],[7]

The fascia lata is a little elastic and hard tissue, difficult to handle, so other tissues such as aortic (more elastic and easier to use) are sought that provide greater comfort to the patient. Dermal grafts that, unlike the previous ones, have an epithelium that does not require a conjunctival covering in its entirety, it is thinner, with greater adherence to the avascular surface; but it produces greater inflammation and follicular growth.[8] The autologous sclera with a pedicle for small defects and a double pedicle for large defects is also described. The tectonic sclera is more rigid than the fascia lata, more difficult to manipulate.[7] The use of dura mater, more difficult to obtain in our environment, is also described;[9] and the amniotic membrane that in cases of extensive defects is not effective.

As fascia lata is a more resistant tissue, compared to dermal grafts and amniotic membrane, the use in patients with a history of the autoimmune disease lasts longer.[8] The periosteum, aortic tissue, cartilage, cornea, and synthetic material produce a greater inflammatory reaction with a higher risk of rejection.

Systemic immunosuppressive treatment is used as initial therapy that interrupts the destructive process, having a good result in small defects. However, there has been an increased risk of perforation in large defects, and hence, it requires surgical treatment to avoid or treat perforation.[10]

The study presents the largest number of cases with short-term follow-up with very good recovery and conservation of the eyeball, in addition to presenting large defects and some perforations. Using autologous tissue, which pathophysiologically has better adherence than a heterologous (risk of disease, greater rejection) makes this technique ideal for the cases described. In addition, many times, we do not have another type of tissue. It does not require additional costs (advantage in developing countries).

The limitations of the study are that it could not be compared with other types of surgical treatments. We hope that in the future an experimental design study can be carried out for further recommendations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nawaiseh IA, Nazzal RM, Nowomiejska K, Toro M, Rejdak R. Scleromalacia perforans as the presenting sign for rheumatoid arthritis — a case report. Ophthalmol J 2019;4:56-59. DOI: 10.5603/OJ.2019.0009.  Back to cited text no. 1
    
2.
Kopacz D, Maciejewicz P, Kopacz M. Scleromalacia perforans–What we know and what we can do. J Clinic Experiment Ophthalmol 2013, S2. DOI: 10.4172/2155-9570.S2-009.  Back to cited text no. 2
    
3.
Thakur S, Agrawal A, Aishwarya A, Tsui E, MD. Scleromalacia perforans. American Academy of Ophthalmology. Available from: https://eyewiki.org/Scleromalacia_Perforans. [Last accessed on 2020 Feb 02].  Back to cited text no. 3
    
4.
der Hoeve V. Scleromalacia perforans. Arch Ophthalmol 1934;11:111.  Back to cited text no. 4
    
5.
Armstrong K, McGovern V. Scleromalacia perforans and repair grafting. Trans Ophthalmol Soc 1955;15:110-21.  Back to cited text no. 5
    
6.
Taffet S, Carter GZ. The use of a fascia lata graft in the treatment of scleromalacia perforans. Am J Ophthalmol 1961;52:693-6.  Back to cited text no. 6
    
7.
George M, Gombos M. Surgical treatment of scleromalacia perforans. Acta Ophthalmol 1967;45:582-6.  Back to cited text no. 7
    
8.
Mauriello JA Jr., Pokorny K. Use of split-thickness dermal grafts to repair corneal and scleral defects – A study of 10 patients. Br J Ophthalmol 1993;77:327-31.  Back to cited text no. 8
    
9.
Enzenauer W, Enzenauer RJ, Reddy VB, Cornell FM, West S. Treatment of scleromalacia perforans with dura mater grafting. Ophthalmic Surg 1992;23:829-32.  Back to cited text no. 9
    
10.
Ghauri M, Urooj Riaz S, Husain A, Raza Jafri A, Ain Bashir ZT. Scleromalacia perforans: A case report. J Med Case Rep 2018;12:155.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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