Graft Loss And Corneascleral Dellen After An Uneventful Ptergium Surgery: A Ni̇ghtmare Of An Opthalmology Resi̇dent

After uncomplicated conjunctival autograft pterygium surgery in a 74-year-old male patient developed dellen, when medical treatments did not work, complications were managed by covering the amniotic membrane.

This was a case report and designed at Departments of ophtalmology , Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey.

A 74-year-old male presented to our clinic with redness, irritation, tearing and vision loss on his both eyes. He had no known ocular or systemic disease, and no prior ocular surgery was documented. Corrected-distance visual acuity was 0.15 logMAR on his right eye and 0.40 logMAR on his left eye. Slit-lamp examination revealed bilateral lower eyelid trichiasis, bilateral primary nasal pterygium (right eye: grade 1, lefte eye grade 3), and grade 3-4 nuclear cataracts. First of all, laser ablation was performed on both eyes for trichiasis. Pterygium removal with conjunctival autograft surgery was planned for the left eye.

Postoperative patient presented with severe stinging and pain on his left eye. It was observed that the graft had melted, and a large corneoscleral dellen was observed on biomicroscopic examination. The corneal thickness was measured as 168 microns at the thinnest location of dellen at AS-OCT. 

Therefore, the amniotic membrane transplantation (AMT) was applied to the patient, who was unresponsive to topical lubricant treatment. 

Meanwhile, the patient was diagnosed with rheumatoid arthritis due to disease specific high level of rheumatism-related antibodies requested by rheumatology and systemic treatment was started.

At the patient's last examination (3 months after AMT), at the thinnest point, AS- OCT corneal thickness measured as 581 microns.

Ocular surface health is one of the most important keys for a successful ophthalmic surgery. In most cases requiring ophthalmic surgery, there is already a pre-existing DED due to reasons such as age, topical and systemic drug use. Ocular surgeries also cause further comprimise of the ocular surface by topical medications used before and after surgery, microscope light toxicity, corneal incision, goblet cell injury during surgery and triggering inflammation.

In this case report we tried to show the management of one of the most serious complications of ptergium surgery and emphasize how preoperative ocular surface and systemic assessments are important for surgical success.