Necrotising fungal scleritis with full-thickness scleral melt and circumferential progression: a novel debridement approach

Necrotizing scleritis due to Hormographiella aspergillata

PURPOSE

To report the management and outcome of a case of necrotizing scleritis due to Hormographiella aspergillata.

METHODS

Case report.

RESULTS

A 79-year-old woman developed scleral inflammation following accidental trauma with a gorse plant in her left eye. An abscess formed at the site of the injury, which was surgically drained. Filamentous fungi were identified from the abscess contents, and oral voriconazole and topical voriconazole and natamycin drops were prescribed. Phenotypic analysis confirmed the presence of Hormographiella aspergillata, with low minimum inhibitory concentrations (MIC) for voriconazole and amphotericin B. Two weeks later the patient presented with an area of necrotizing scleritis which required surgical debridement and scleral grafting. Three months later, the scleral inflammation had resolved leaving an area of scleromalacia.

CONCLUSIONS

Hormographiella aspergillata is a common environmental fungus that has recently emerged as a human pathogen and a rare cause of scleritis. To the best of our knowledge, this is the first report of scleritis in which a pure culture of H. aspergillata was obtained. Successful management poses a challenge as there are limited reports on antifungal susceptibility and a combination of medical and surgical treatment is often required.

Possible Synergistic Role of Cryo-Alcohol Therapy in Infectious Scleritis-Scope and Rationale for Expanding Indications and Review of the Literature

PURPOSE

The purpose of this study was to highlight the use of topical ethanol as an adjunct to cryotherapy, termed cryo-alcohol therapy, in the management of fungal/acanthamoeba scleritis along with a review of the literature.

METHOD

Retrospective interventional case reports of fungal and acanthamoeba scleritis along with a review of the literature.

RESULTS

The patient with circumferential necrotic fungal scleritis resolved in 6 weeks achieving a best-corrected visual acuity (BCVA) of 20/20, and the patient with acanthamoeba scleritis is awaiting optical keratoplasty after complete resolution in 8 weeks. The literature review from January 1990 to December 2020 revealed BCVA >20/200 in 50% of the eyes with a mean time to resolution being 4.16 ± 2.13 months in fungal scleritis, with 27.02% and 75% of the eyes requiring evisceration in fungal and acanthamoeba scleritis, respectively.

CONCLUSIONS

Cryotherapy is a useful adjunct in managing refractory infectious scleritis, and its efficacy can be enhanced by combining the use of topical ethanol to aid in faster recovery and reduce visual morbidity.