June consultation #3

Abstract

The inferior scleral thinning is concerning and warrants a systemic workup to rule out autoimmune (ie, rheumatoid arthritis and systemic lupus erythematous) and infectious etiologies for scleritis. Laboratory workup should include complete blood count (CBC), erythrocyte sedimentation rate (ESR), rapid plasma reagin (RPR), fluorescent treponemal antibody absorption test (FTA-abs), antinuclear antibodies (ANAs), rheumatoid factor (RF), C3, C4, cANCA (antineutrophil cytoplasmic antibodies), pANCA, and C-reactive protein (CRP). The lack of pain is reassuring but there are cases of necrotizing scleritis without inflammation due to rheumatoid arthritis that may be missed. It is helpful to be aware of scleritis as there are more risks with any surgical intervention, and immunosuppression may be needed.Even if the etiology of glaucoma is not known, we must now control it. The inferior site may likely be left alone as the iris incarceration can serve as a lifetime patch to guard the site. If this thin area is of concern, we suggest reinforcing the sclera with a corneal patch graft (sclera or pericardium can be used but will be more cosmetically noticeable). We would avoid angle surgery, which can further compromise the blood-aqueous barrier and lead to worsening inflammation. We have found tube shunts to be the most predictable option. One may consider a superotemporal Ahmed FP-7 device (New World Medical, Inc.) for immediate IOP control; however, given the patient's young age, we believe small, nonvalved implants work better in long-term; we would consider an Ahmed ClearPath 250 (New World Medical, Inc.) device (Figure 5) or a 245 mm 2 Molteno (Nova Eye Medical, Inc.) or BAERVELDT (Johnson & Johnson Vision) implant, with a good number of fenestrations to provide immediate (but temporary) IOP control. We suggest tying off the tube shunt with a 7-0 Prolene suture with a 4-0 nylon suture ripcord in the lumen of the tube, tucked in the inferotemporal subconjunctival space. This would provide immediate IOP relief while allowing for complete control of the IOP if it starts to increase. The ripcord can be removed later in clinic, when needed.Although not the situation in this case, we would like to emphasize that theoretically, perilimbal thinning may reflect enhanced uveoscleral outflow through thin sclera. To the authors' knowledge, the concept of enhanced uveoscleral outflow through thin sclera as the source of a spontaneous perilimbal bleb has not been previously reported.