Tectonic corneal lamellar grafting for severe scleral melting after pterygium surgery

PURPOSE: To describe the technique and review the indications and success of tectonic corneal lamellar grafting for the management of severe scleral melts after pterygium surgery. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Twenty cases of severe scleral necrosis after pterygium surgery (1993-1999). INTERVENTION: Tectonic corneal lamellar grafting. Surgery involved (1) removal of all devitalized or infected scleral tissue surrounding the melt; (2) use of lamellar or full-thickness donor corneal tissue, fashioned to fit the scleral defect exactly or a 0.25-mm diameter larger; and (3) placement of a pedicled or free conjunctival flap over the corneal lamellar graft. MAIN OUTCOME MEASURES: Eradication of progressive scleral necrosis, preservation of globe integrity, eradication of infection, and preoperative and postoperative visual acuity. RESULTS: Sixteen (80%) of 20 cases developed severe scleral necrosis that required tectonic surgery after bare sclera pterygium excision with mitomycin C or beta-irradiation. Surgery was also therapeutic to eradicate progressive infection in 6 cases of infective scleritis that did not respond to maximal medical treatment. Scleral melting presented 1 month to 20 years after initial pterygium surgery in healthy, immune-competent adults. Therapeutic and tectonic success was achieved in 19 cases (95%); in 1 case, recurrence of fusarium fungal infection led to severe graft necrosis and intraocular spread. Among the cases of infectious scleritis, three eyes required repeat lamellar grafting to successfully eradicate infection. CONCLUSIONS: Tectonic and therapeutic lamellar keratoplasty, combined with aggressive antibiotic therapy, preserved globe integrity and eradicated infection in cases of severe scleral melting after pterygium surgery.