Topical erythropoietin in the management of scleral necrosis: a narrative review.

Abstract

Scleral necrosis is a rare but severe complication caused by various etiologies. The main therapeutic approach is topical and systemic medical treatment. Surgical interventions may be indicated in unresponsive cases. These approaches, however, may fail to control the scleral necrosis. In addition, both medical and surgical treatment may lead to a number of ocular and systemic side effects, calling for noninvasive but effective treatment for the management of scleral necrosis. This review aims to summarize current studies investigating the role of topical erythropoietin in the treatment of scleral necrosis caused by various etiologies. Different electronic databases were extensively searched for relevant studies published until May 30, 2025, using the following keywords: "erythropoietin" AND "scleral necrosis" OR "necrotizing scleritis" OR "scleral ischemia." The primary outcomes assessed were the indication for topical erythropoietin administration, with secondary outcomes including the efficacy and ocular and systemic safety of treatment with this medication. Seven studies reported the outcomes of the administration of topical erythropoietin for the treatment of scleral necrosis. Of which, two were experimental studies, two were single case reports, including three eyes of two patients, two were case series, including 11 eyes of 11 patients, and one was a nonrandomized case-control study, including 11 eyes of nine patients. Etiologies for scleral necrosis were chemical burns in 15 eyes, thermal burn in one eye, surgically-induced scleral necrosis in six eyes, and systemic autoimmune diseases in three eyes. The necrotic lesions were improved in all eyes 9-90 days after the initiation of treatment with topical erythropoietin. Regarding ocular safety, two eyes developed granulation tissue, which resolved after the cessation of the treatment. Corneal vascularization was observed in 16 eyes with limbal stem cell deficiency due to chemical/thermal burns. No intraocular vascularization or systemic adverse reactions were observed during treatment with topical erythropoietin. Topical administration of erythropoietin can be safe and effective for the management of scleral necrosis caused by various etiologies. However, more studies, including randomized clinical trials, are needed to establish the role of topical erythropoietin in the treatment of this rare but sight-threatening complication.