Amniotic membrane transplantation for necrotising conjunctival ulceration following subconjunctival atropine injection

Conjunctival necrosis has been previously reported after subconjunctival injection of several antimicrobial agents and corticosteroids.^1–3 Atropine is used widely as a form of eyedrops for mydriasis, cycloplegia, and pain and inflammation control. We describe a patient who developed severe conjunctival necrosis associated with scleral melting after subconjunctival atropine injection and which was treated by amniotic membrane transplantation.

Case report

A 30 year old male patient visited our clinic because of severe pain and redness in his left eye for a day. He had recently been diagnosed with uveitis associated with circular posterior synechiae in his left eye, and which was managed by his previous physician with a subconjunctival injection of 0.4 ml of atropine (10 mg/ml, atropine sulphate, powder dissolved in saline, Mallinckrodt, St Louis, MO, USA) to lyse the posterior synechiae. Upon consultation at our institute, he was found to have marked conjunctival injection and chemosis all around the limbus. Three days after the atropine injection, large areas of necrosis developed around the whole limbus (Fig 1). White necrotic materials were noted on the underlying sclera and episclera. The underlying sclera in the inferotemporal bulbar conjunctiva showed a considerable area of melting (2 × 3 mm).

Figure 1.

(A) The left eye showing large areas of necrosis developed around limbus. (B) Conjunctival necrosis and marked conjunctival injection in the superior bulbar conjunctiva.

We decided to manage the defect by amniotic membrane transplantation to the sclera because of the large extent of the defect and the scleral involvement. Debridement of the necrotic conjunctiva and episclera was done and the defect was covered with an amniotic membrane graft, which was obtained from women undergoing elective caesarean section and preserved at −70°C. The amniotic membrane was placed basement membrane side up and the excess membrane was trimmed. The edges of them were sutured to the borders of the conjunctiva and the limus with 10-0 nylon. Topical 0.3% ofloxacin and 1% prednisolone acetate were prescribed every 2 hours postoperatively.

For the next week, the patient improved steadily, having less pain and redness. After a month, the necrotised defect was re-epithelialised completely without inflammation, scar, or symblepharon formation (Fig 2). The eyedrops were tapered to four times daily for 2 weeks, twice daily for more 2 weeks, and then stopped.

Figure 2.

(A) Slit lamp photograph of left eye 1 month after treatment. The conjunctiva is completely healed. (B) The necrotised defect in the superior conjunctiva was re-epithelialised without any scar formation or symblepharon.

Comment

Subconjunctival atropine has been a useful management for the equine ophthalmic disorder including equine recurrent uveitis, many ulcerative keratopathies, and presurgical and postsurgical cataract extraction.⁴ In humans, however, the procedure of subconjunctival injection with atropine has been used infrequently. Our case shows that subconjunctivally delivered atropine should be approached with some degree of caution in humans.

The necrotising conjunctival ulceration in this case covered a large area and was also associated with scleral melting. It was rapidly healed after amniotic membrane transplantation without scleral perforation or symblepharon formation. Transplanted amniotic membrane has been known to provide a thick basement membrane to facilitate epithelial migration, play a part in decreasing inflammation and proteinase activity, and function as an anatomic barrier, keeping the adhesive surfaces apart.^5–9 In our case, some combination of the mentioned characteristics would work for treating a severe necrotising conjunctival ulceration with the potential risk of symblepharon and perforation.