What is the treatment for an injected sclera?

Treatment of Injected Sclera

For persistent injection over a surgical site, the American Academy of Ophthalmology recommends observation with topical medications as first-line management, since this is typically a mild, self-limited postoperative concern. 1

Initial Assessment and Classification

When encountering an injected sclera, first determine the underlying etiology:

• Post-surgical injection: Common after strabismus surgery, refractive procedures, or other ocular surgeries—typically benign and self-resolving 1
• Inflammatory scleritis: Requires urgent evaluation for autoimmune disease, particularly rheumatoid arthritis, as this can rapidly destroy the eye and vision 2
• Infectious causes: Rare but serious complications including preseptal/orbital cellulitis (1 in 1,100 to 1 in 1,900 after strabismus surgery) or subconjunctival abscess 1

Treatment Algorithm Based on Severity

Mild Postoperative Injection (Most Common)

Conservative management is appropriate for routine postoperative scleral injection:

• Topical medications are the mainstay of treatment 1
• Observation is acceptable as most cases are self-limited 1
• No specific antibiotic regimen is required unless infection is suspected 1

Moderate Concerns Requiring Active Monitoring

For persistent injection with associated findings:

• Pyogenic granuloma: May resolve spontaneously or require treatment with excision, steroids, or topical beta-blockers (occurs in 2.1% of strabismus cases) 1
• Visible sclera or dark sclera: Generally cosmetic concerns that do not require intervention 1
• Tenon's prolapse or advancing plica semilunaris: Typically managed conservatively 1

Serious Complications Requiring Urgent Intervention

Surgically induced necrotizing scleritis (1 in 4,000, more likely in adults) demands immediate aggressive management:

• This represents an autoimmune-mediated destruction of scleral tissue with infiltration by macrophages and T-lymphocytes 2
• Requires consultation with rheumatology and potentially infectious disease specialists 1
• May necessitate systemic immunosuppression 2

Infectious scleritis or endophthalmitis:

• Endophthalmitis occurs in 1 in 30,000 to 1 in 185,000 cases post-surgery 1
• Requires immediate ophthalmologic intervention with intravitreal antibiotics
• Topical antibiotics alone are insufficient 3, 4

Specific Treatment Modalities

Topical Therapy

For bacterial conjunctivitis or superficial infection:

• Use FDA-approved ophthalmic fluoroquinolones (moxifloxacin, gatifloxacin, ciprofloxacin) 3, 5
• Never use non-sterile dermatologic preparations like mupirocin ointment, as these can cause severe bacterial keratitis, corneal ulceration, or endophthalmitis 3
• Fluoroquinolone drops are preferred over ointments for achieving higher tissue levels 3

Corticosteroid Considerations

Steroids should be used cautiously and only after ruling out infection:

• The American Academy of Ophthalmology recommends against combination steroid-antibiotic drops as initial monotherapy for suspected bacterial involvement 4
• Add corticosteroids only after 2-3 days of antibiotic therapy once the organism is identified 4
• Conjunctival necrosis and scleritis are documented complications of periocular corticosteroid injections 6

Critical Pitfalls to Avoid

Common errors in managing injected sclera:

• Delaying appropriate treatment: Using ineffective agents can lead to vision-threatening complications 3
• Misdiagnosing necrotizing scleritis: This rare but devastating complication (1 in 4,000) requires immediate subspecialty consultation 1
• Overlooking systemic disease: Scleritis may be concurrent with rheumatoid arthritis or other autoimmune conditions 2
• Using non-ophthalmic preparations: Non-sterile formulations risk introducing severe infection 3

When to Refer

Immediate ophthalmologic evaluation is required for:

• Irregular pupil after trauma 3
• Eye bleeding or vision loss 3
• Increasing pain or purulent discharge 3
• Suspected necrotizing scleritis 1
• No improvement within 48 hours of appropriate antibiotic therapy 4

Subspecialty consultation may be indicated for:

• Retina specialists for complications like retinal detachment (1 in 10,000 to 1 in 40,000) 1
• Rheumatology for suspected autoimmune scleritis 1, 2
• Infectious disease for refractory infections 1