Spontaneous Regression of Traumatic Scleral Staphyloma Following Intraocular Pressure Control : A Case report

Technical Summary: Spontaneous Regression of Traumatic Scleral Staphyloma Following Intraocular Pressure Control

Problem Statement
Ocular trauma is a primary cause of global visual impairment. While primary emergency suturing is the standard for preserving anatomical structure, complex trauma—particularly involving posterior scleral wounds, large uveal/retinal defects, or occult scleral expansion—can lead to severe structural complications in the mid-to-late postoperative period. One such complication is traumatic scleral staphyloma, defined as a progressive, tumor-like bulging of the sclera caused by normal or elevated intraocular pressure (IOP) acting on a weakened, scarred eye wall. This condition represents abnormal wound healing where damaged scleral tissue is replaced by fibrous scars lacking elasticity. Traditionally, the management of such staphylomas often implies surgical intervention; however, the reversibility of this condition through non-surgical means remains an area requiring further clinical evidence.

Methodology
This study presents a single-case report of a 50-year-old male who sustained a ruptured globe injury to the left eye from a wooden stake. The patient underwent primary repair and a subsequent exploratory surgery for wound dehiscence. Approximately two months post-operatively, the patient presented with a bluish-gray scleral staphyloma (3 × 12 mm) at the corneoscleral limbus and significantly elevated IOP (32 mmHg).

Instead of immediate surgical repair of the staphyloma, the clinical team initiated a conservative management strategy focused solely on pharmacological IOP control. The treatment regimen consisted of triple anti-glaucoma therapy:

• Brinzolamide
• Carteolol
• Brimonidine tartrate

This approach was selected to inhibit aqueous humor production and promote drainage via the uveoscleral pathway while avoiding prostaglandin analogs that could exacerbate inflammation. The patient was monitored over a three-month period to assess changes in IOP, staphyloma dimensions, and ocular structural integrity.

Key Results
Following three months of pharmacological intervention, the patient exhibited significant clinical improvement:

• IOP Control: Intraocular pressure normalized from 32 mmHg to 13.8 mmHg.
• Staphyloma Regression: The staphyloma demonstrated marked regression, reducing in size from 3 × 12 mm to a residual lesion of 1.5 × 3 mm.
• Ocular Health: The conjunctiva became non-injected, corneal edema resolved, and the anterior chamber remained well-formed. Fundus examination revealed a distinct optic disc with normal color and an attached retina, with no evidence of glaucomatous cupping.
• Visual Acuity: Best-corrected visual acuity improved from hand motion at 10 cm to hand motion at 20 cm.

Key Contributions
The primary contribution of this case report is the documentation of a rare instance where a traumatic scleral staphyloma underwent remarkable spontaneous regression following IOP control alone, without surgical repair of the staphyloma itself. The authors propose that the formation of this specific staphyloma was primarily driven by passive expansion due to elevated IOP acting on a weakened scleral area, rather than irreversible destruction of the scleral collagen structure. Consequently, the normalization of IOP allowed for elastic retraction of the local scleral tissue and scar remodeling, facilitating partial recovery of the bulging lesion.

Significance and Claims
The paper posits that not all traumatic scleral staphylomas necessitate immediate surgical repair. In the absence of active leakage or infection, aggressive pharmacological reduction of IOP may lead to reversible regression in selected patients. The authors suggest that for post-traumatic secondary scleral staphylomas where the etiology is reversible (specifically elevated IOP), conservative management should be prioritized.

The study emphasizes that if the staphyloma does not improve after IOP lowering, surgical interventions such as allogenic scleral grafting may still be required. Furthermore, the case highlights the critical importance of regular follow-up during the high-risk postoperative period (1 to 3 months) to detect and manage secondary complications like intraocular hypertension early. This report provides new evidence supporting a conservative, IOP-focused management strategy for a subset of traumatic scleral staphylomas.