Intrascleral dissemination of infectious scleritis following pterygium excision

Necrotizing Scleritis: A Review

Necrotizing scleritis is the most destructive and vision-threatening form of scleritis. Necrotizing scleritis can occur in systemic autoimmune disorders and systemic vasculitis, as well as following microbial infection. Rheumatoid arthritis and granulomatosis with polyangiitis remain the commonest identifiable systemic diseases associated with necrotising scleritis. Pseudomonas species is the most common organism causing infectious necrotizing scleritis, with surgery the most common risk factor. Necrotizing scleritis has the highest rates of complications and is more prone to secondary glaucoma and cataract than other phenotypes of scleritis. The differentiation between non-infectious and infectious necrotizing scleritis is not always easy but is critical in the management of necrotizing scleritis. Non-infectious necrotizing scleritis requires aggressive treatment with combination immunosuppressive therapy. Infectious scleritis is often recalcitrant and difficult to control, requiring long-term antimicrobial therapy and surgical debridement with drainage and patch grafting due to deep-seated infection and the avascularity of the sclera.

Infectious Scleritis - Clinical Characteristics, Causative Factors, and Treatment Outcomes in an Indian Population

PURPOSE

To study the clinical features, causative factors and treatment outcomes in patients with infectious scleritis seen in India.

METHODS

A retrospective study of all patients examined at a tertiary care center between August 2012 and March 2021.

RESULTS

Forty-five patients (45 eyes; mean age 52.7 ± 17.5 years) were included in the study. The mean duration of symptoms was 3.1 ± 4.4 months. Inciting factors were found in 53.3% (injury: 33.3%; ocular surgery: 20.0%). The scleritis was predominantly anterior (97.8%), with multiple lesions in 40.0%, a solitary lesion in 31.1%, and diffuse in 28.9%. Associated features included uveitis (51.1%), keratitis (37.8%), hypopyon (15.6%), and endophthalmitis (6.7%). Causative organisms included bacteria (53.3%), fungi (35.6%), and presumed herpes virus (11.1%). All patients were treated with antimicrobial agents along with systemic corticosteroids where indicated. Surgical treatment included scleral debridement (37.8%), patch grafts (4.4%), and penetrating keratoplasty (2.2%). Complete resolution of scleritis was seen in 86.7%, with a mean duration of therapy of 2.9 ± 2.5 months. The mean follow-up was 8.3 ± 14.3 months. 51.1% of patients lost functional vision (<6/60). Causes of decreased vision included corneal scar, cataract, macular scar, glaucomatous optic atrophy, and phthisis bulbi. On bivariate analysis, poor visual acuity at presentation was associated with a worse visual outcome (p = 0.02). Other risk factors included necrotizing scleritis, multifocal scleritis, the presence of keratitis and uveitis.

CONCLUSION

In our study, infectious scleritis resulted from bacterial and fungal infections. The scleritis resolved in most subjects, however, vision loss was frequent due to infection-related complications.

Determinants of Clinical Outcomes After Infectious Scleritis

PURPOSE

The aims of this study were to describe the clinical course of microbial infectious scleritis and identify factors associated with poor visual outcomes.

METHODS

Data from 26 eyes of 26 patients with culture-proven bacterial or fungal scleritis presenting at a single tertiary center from January 1, 2007, to July 1, 2021, were reviewed. Thirty-six variables were analyzed for associations with poor vision [best-corrected visual acuity (BCVA) <20/200] or loss of vision (no light perception vision or requirement for enucleation or evisceration) at final visit.

RESULTS

The mean age at initial presentation was 67.1 ± 14.0 (range: 34-92) years with a mean follow-up of 2.1 ± 2.2 (0.05-8.45) years. The mean presenting logarithm of minimal angle of resolution (logMAR) BCVA was 1.3 ± 1.0 (∼20/400) and mean final logMAR BCVA was 1.6 ± 1.2 (∼20/800). Fourteen eyes (53.8%) exhibited poor vision and 7 (26.9%) had loss of vision at final follow-up. History of necrotizing scleritis and poor presenting vision were associated with poor final vision (OR = 19.1; P = 0.017 and OR = 7.5; P = 0.047, respectively), whereas fungal scleritis was associated with loss of vision (odds ratio [OR] = 30.3, P = 0.013). Subconjunctival antimicrobial treatment was inversely associated with loss of vision (OR = 0.06, P = 0.023). There was no difference in vision between medical and combined medical-surgical management, although infection resolution time was shorter for combined intervention (16.8 ± 10.6 vs. 53.7 ± 33.8 days; P = 0.005).

CONCLUSIONS

Infectious scleritis is often successfully treated, but loss of vision or eye removal is common. Poor baseline vision, history of necrotizing scleritis, and fungal etiology were prognostic for worse clinical outcomes. Surgical intervention was associated with quicker resolution compared with medical treatment alone.

Ocular infections associated with atypical mycobacteria: A review

Atypical mycobacteria or non-tuberculous mycobacteria (NTM) are a group of acid-fast bacteria that are pathogenic to different parts of the eye. The organisms can cause a spectrum of ocular infections including keratitis, scleritis, uveitis, endophthalmitis and orbital cellulitis. Trauma, whether surgical or nonsurgical, has the highest correlation with development of this infection. Common surgeries after which these infections have been reported include laser in situ keratomileusis (LASIK) and scleral buckle surgery. The organism is noted to form biofilms with sequestration of the microbe at different inaccessible locations leading to high virulence. Collection of infective ocular material (corneal scraping/necrotic scleral tissue/abscess material/vitreous aspirate, etc.) and laboratory identification of the organism through microbiologic testing are vital for confirming presence of the infection and initiating treatment. In cluster infections, tracing the source of infection in the hospital setting via testing of different in-house samples is equally important to prevent further occurrences. Although the incidence of these infections is low, their presence can cause prolonged disease that may often be resistant to medical therapy alone. In this review, we describe the various types of NTM-ocular infections, their clinical presentation, laboratory diagnosis, management, and outcomes.

Atypical microbial keratitis

Atypical microbial keratitis refers to corneal infections caused by micro-organisms not commonly encountered in clinical practice. Unlike infections caused by common bacteria, cases of atypical microbial keratitis are often associated with worse clinical outcomes and visual prognosis. This is due to the challenges in the identification of causative organisms with standard diagnostic techniques, resulting in delays in the initiation of appropriate therapies. Furthermore, due to the comparatively lower incidence of atypical microbial keratitis, there is limited literature on effective management strategies for some of these difficult to manage corneal infections. This review highlights the current management and available evidence of atypical microbial keratitis, focusing on atypical mycobacteria keratitis, nocardia keratitis, achromobacter keratitis, and pythium keratitis. It will also describe the management of two uncommonly encountered conditions, infectious crystalline keratopathy and post-refractive infectious keratitis. This review can be used as a guide for clinicians managing patients with such challenging corneal infections.

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.

Pseudomonas aeruginosa Scleritis following Pterygium Surgery with Mitomycin C or Beta Irradiation: Three-Case Report

Purpose

To report three cases of culture-positive Pseudomonas aeruginosa scleritis following pterygium surgery. Patients and Methods. A retrospective study of all patients of Pseudomonas aeruginosa scleritis after pterygium surgery presented from May 2017 to May 2020 was performed. Patient demographics and clinical characteristics included age, gender, time between prior surgery and onset, adjunctive therapy, risk factors, initial visual acuity, final visual acuity, clinical features, medical treatment, and surgical intervention were analyzed.

Results

Three eyes of three patients with clinical characteristics and laboratory-confirmed Pseudomonas aeruginosa scleritis were identified. Two patients were related with mitomycin C application after pterygium surgery, and only one had beta irradiation. Antibiotic administration and scleral debridement were required in 3 patients. One eye was enucleated. Final visual outcomes of two patients were improved.

Conclusions

Pseudomonas aeruginosa scleritis after pterygium surgery is a crucial ophthalmic disease. An early diagnosis with a prompt intensive antibiotic treatment in combination with surgical interventions may improve visual outcome.

A case of anterior scleritis in association with posterior scleritis - a diagnostic riddle

We herein report a case of a young female presenting with multiple nodular scleral abscesses mimicking infective scleritis with exudative retinal detachment. Repeated diagnostic scraping for microbiological and histopathological analysis was inconclusive. The patient's systemic and collagen disease work-up was non-contributory. She was treated with multiple surgical debridement and de-roofing of the abscesses along with antibiotic irrigation. Topical and oral steroid was stopped on worsening of the condition, and the patient was maintained on topical and oral antibiotics. Complete resolution of scleritis and exudative detachment was noted at 1 month follow-up and no recurrence was noted until 6 months.

A novel technique of full-thickness scleral debridement in fulminant necrotising infectious scleritis and its outcomes-a consecutive case series

PURPOSE

To report the outcomes of a novel technique of scleral debridement in five consecutive cases of relentlessly progressive and fulminant infectious scleritis following corticosteroid exposure.

METHODS

Five consecutive patients of infectious scleritis with a common history of corticosteroids exposure, resulting from either an initial misdiagnosis of autoimmune scleritis or as anti-inflammatory adjunct to specific antimicrobial therapy. Data collection included presentation details such as photographs, clinical findings, microbiological analysis, treatment details and audit of surgical videos. Cases with undisputed diagnosis of infectious scleritis with microbiological evidence, without corticosteroid use, were excluded from  the study.

RESULTS

After full-thickness scleral debridement and cessation of corticosteroids, favourable anatomical and visual outcome was observed in all cases; however, two patients required multiple scleral debridements due to progressive scleritis. Scleral patch graft was not used in any case. Microbiology detected infective organisms in two cases, while the remaining revealed negative results. Therefore, specific antimicrobial therapy was initiated in former, whereas empirical broad-spectrum regimen in patients with repeatedly negative microbiological results. No recurrence of scleritis or development of ciliary staphyloma was noted and anatomical integrity was maintained with normal intraocular pressure during follow-up.

CONCLUSION

This study highlights the fulminant and relentlessly progressive clinical course, that infectious scleritis can metamorphose into, despite specific antimicrobial therapy, if inadvertent corticosteroid therapy is administered. Full-thickness debridement without scleral patch graft, could achieve elimination of infectious foci, with favourable long-term anatomical and visual outcome. This technique could offer a potential last-resort approach in such cases where standard therapeutic modalities have not been successful.

Infectious Scleritis: Pathophysiology, Diagnosis, and Management

ABSTRACT

Infectious scleritis (IS) is a rare and severe ocular disorder responsible for approximately 5%-15% of all scleritis cases. It is often associated with a poor prognosis due to its similar clinical presentation to autoimmune scleritis, resulting in a delayed diagnosis and treatment. Therefore, differentiating between infectious and noninfectious entities is critical. Several details extracted from the patient's history and clinical examination can raise suspicion for infection. The most common predisposing factor is previous ocular surgery, especially pterygium, cataract, and vitreoretinal surgeries. Ocular trauma, poor contact lens hygiene, "eye-whitening" procedures, and subtenon triamcinolone injections have also been implicated. Clinical features of infection include the presence of scleral necrosis, hypopyon, unifocal or multifocal scleral abscesses, and mucopurulent discharge. Thorough diagnostic testing is essential before excluding infection as a possibility. Empiric broad-spectrum topical and systemic antibiotic therapy should be initiated while awaiting laboratory results and adjusted accordingly. Most IS cases require both aggressive medical and surgical treatment, and various studies have reported favorable outcomes with this combination. At this time, there is no consensus on the management of this severe ocular condition, and future studies are needed to establish clear treatment guidelines.

Sterile subconjunctival abscess in an HLA-B51-positive patient with ulcerative colitis

Purpose

To report a rare case of aseptic abscess presenting as a subconjunctival abscess in an HLA-B51-positive patient with ulcerative colitis.

Observations

A 25-year-old, male, Japanese patient with ulcerative colitis presented with an unilateral subconjunctival abscess. Infective endocarditis with endophthalmitis was suspected of being the cause, and systemic antimicrobial therapy was begun. The patient became critically ill and experienced the complication of heart failure with mitral valve perforation but improved dramatically with high-dose corticosteroids and intravenous infliximab following mitral valvuloplasty. His HLA typing was positive for HLA-B51.

Conclusions and importance

Both infectious and non-infectious etiologies should be considered in a patient with a subconjunctival abscess with systemic inflammation. An aseptic abscess can present as a subconjunctival abscess, and HLA-B51 may play a role in the pathogenesis of this rare condition.

The clinical and pathogenic spectrum of surgically-induced scleral necrosis: A review

The onset of scleral necrosis after ocular surgery may have catastrophic ocular and systemic consequences. The two most frequent surgeries causing surgically-induced scleral necrosis (SISN) are pterygium excision and cataract extraction. Several pathogenic mechanisms are involved in surgically induced scleral necrosis. All of them are poorly understood. Ocular trauma increasing lytic action of collagenases with subsequent collagen degradation, vascular disruption leading to local ischemia, and immune complex deposition activating the complement system represents some of the events that lead to scleral necrosis. The complex cascade of events involving different pathogenic mechanisms and the patient's abnormal immune response frequently leads to delayed wound healing that predisposes the development of scleral necrosis. The management of SISN ranges from short-term systemic anti-inflammatory drugs to aggressive immunosuppressive therapy and surgical repair. Therefore, before performing any ocular surgery involving the sclera, a thorough ophthalmic and systemic evaluation must be done to identify high-risk patients that may develop SISN.

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

A 44-year-old Asian Indian woman presented with a history of pain and redness in the left eye for 3 weeks. Scleral congestion with a nodular swelling was present inferotemporally. Raised C reactive protein and positive antinuclear and perinuclear antineutrophil cytoplasmic antibodies suggested autoimmune scleritis. The patient was therefore managed with corticosteroids. Nevertheless, the development of severe pain associated with a scleral abscess led to a revised diagnosis of infectious scleritis. Corticosteroids therapy was halted and urgent debridement was performed. Microbiology confirmed fungal scleritis due to Coprinopsis cinerea Multiple full-thickness circumferential debridements with antifungal therapy resulted in satisfactory anatomical and visual outcomes. This case presented a unique challenge, since laboratory results were misleading, and corticosteroids resulted in a fulminant clinical course. Therefore, aggressive circumferential debridement was performed to achieve the elimination of a rare fungal aetiology of scleritis, which has not been reported previously to cause human infection.

Mycobacterium haemophilum scleritis: two case reports and review of literature

Background

Mycobacterium haemophilum is a rare and emerging nontuberculous mycobacteria (NTM). It normally causes localized or disseminated systemic diseases, particularly skin infections and arthritis in severely immunocompromised patients. There have been 5 cases of M. haemophilum ocular infections reported in the literature. Only 1 case presented with scleritis with keratitis. Here, we reported 2 cases of M. haemophilum scleritis. One of them was immunocompetent host and had keratitis with radial keratoneuritis as a presenting sign.

Case presentation

Case 1: A 52-year-old Thai female with rheumatoid arthritis presented with scleritis. Conjunctival scraping was carried out and the culture result was positive for M. haemophilum. Despite receiving systemic and topical antibiotics, her clinical symptoms and signs worsened. Surgical debridement was performed. After surgery, the lesion was significantly improved and finally turned to conjunctival scarring. Case 2: A 32-year old healthy Thai male without underlying disease presented with nodular scleritis and keratouveitis with multiple radial keratoneuritis. Surgical debridement of the scleral nodule was performed. Initial microbiological investigations were negative. Herpes ocular infections was suspected. Topical antibiotics, oral acyclovir, low-dose topical steroids and systemic steroids were started. The scleral inflammation subsided but later the keratitis relapsed, requiring corneal biopsy. Histopathology of the specimen revealed acid-fast bacteria and M. haemophilum was identified by polymerase chain reaction (PCR) and sequencing. The diagnosis of Mycobacterial keratitis was made. Although using the combination of systemic and topical antibiotics, his clinical status progressively deteriorated. Multiple therapeutic penetrating keratoplasties were required to eradicate the infection. No recurrence was found during the 1-year follow-up in both cases.

Conclusions

M. haemophilum can cause scleritis and keratitis, even in immunocompenent host. Radial keraoneuritis is first described in M. haemophilum keratitis. NTM keratitis should be considered in the differential diagnosis of patients with radial keratoneuritis. Increased awareness and early diagnosis using appropriate culture conditions and molecular techniques are important for the proper treatment of this infection. Prompt surgical intervention appears to be vital for successful management of M. haemophilum scleritis and keratitis.

Scleritis: Differentiating infectious from non-infectious entities

Scleritis is a rare painful ocular disorder, associated with severe ocular pain and tissue destruction. Although a majority of these cases are immune mediated and at least half of these are associated with systemic immune-mediated diseases, a smaller minority are due to infections of the sclera. The two conditions closely mimic each other, and a thorough knowledge of the subtle differences is necessary in order to reach a timely diagnosis. Diagnostic delay can lead to a poor outcome both due to the destruction caused by the uncontrolled infection and also due to propagation of the infection with the use of corticosteroids which may have been started for presumed immune mediated scleritis. In this review, we present the clinical features, etiological agents, and the differentiating features between immune and infectious scleritis. We also present diagnostic and management guidelines for managing scleral infection.

Identification and antifungal sensitivity of two new species of Diaporthe isolated

Diaporhte species are plant pathogens rarely involved in human diseases, especially eye diseases. We report our findings in two undescribed Diaporhte species. Both were identified by their morphological characteristics and by DNA sequence analyses. In Case 1, an 81-year-old male farmer who had pterygium surgery 7 years earlier developed keratitis and the causal fungus was identified as a new species of Diaporthe, D. oculi. This species can be distinguished from the closely related D. limonicola on Citrus limon (Rutaceae) by the ITS, tef1, and TUB (515/520 = 99.0% in ITS, 315/324 = 97.2% in tef1, and 601/614 = 97.9% in TUB). The isolate from Case 2, a 68-year-old man with a rose thorn injury, was also identified as a new Diaporthe species, D. pseudooculi. Phylogenetically, D. pseudooculi is different from the closely related D. podocarpi-macrophylli by the ITS, tef1, and TUB (525/531 = 98.9% in ITS, 314/333 = 94.3% in tef1, and 436/442 = 98.6% in TUB). We report on the identification, drug sensitivity, and treatment outcomes for these two new species of Diaporthe, D. oculi and D. pseudooculi.

Interventions and Outcomes in Patients with Infectious Pseudomonas scleritis: A 10-Year Perspective

Purpose: To identify interventional factors associated with improved visual results and faster time to resolution for patients with Pseudomonas scleritis. Methods: Retrospective study analyzing inciting factors, therapeutic modalities, and outcomes of patients with Pseudomonas scleritis. Results: A total of 24 patients were analyzed; 22 were treated as outpatients. All had resolution of infection and 58% (n = 14) maintained ≥20/200 vision. Medical therapy included topical and oral antibiotics; seven received additional subconjunctival injections; two were admitted for IV antibiotics. Patients presenting with ≥20/200 vision were more likely to maintain this level of vision (n = 8, 80%) compared to those presenting with severe vision loss (n = 5, 36%) (p = 0.04). A similar proportion of patients who received (n = 8, 61%) and did not receive (n = 5, 39%) oral steroids achieved 20/200 vision or better once infection resolved, p = 1.0. Conclusions: Pseudomonas scleritis can be successfully managed in the outpatient setting. Oral steroids do not appear harmful in the treatment of this disease.

Pseudomonas Scleritis following Pterygium Excision

Purpose

The aim of this case report was to describe a patient who presented with Pseudomonas scleritis after pterygium excision. The study was conducted at the Department of Ophthalmology, Faculty of Medicine, Chiang Mai University in Chiang Mai, Thailand.

Methods

The record of a patient who was diagnosed as Pseudomonas scleritis after pterygium excision was retrospectively reviewed for history, clinical characteristics, laboratory findings, treatments, and outcomes.

Results

We described a 66-year-old male patient with a history of pterygium excision in his right eye 10 years ago, he presented with infectious scleritis. Scleral thinning, tissue necrosis, and overlying calcified plaque were found. The culture of scleral scraping revealed Pseudomonas aeruginosa. Topical fortified amikacin (20 mg/mL) and intravenous ceftazidime were started. Urgent surgical debridement of scleral infiltrates and irrigation of necrotic sclera and surrounding conjunctiva with fortified amikacin (20 mg/mL) were performed. After 2 weeks of treatment, scleral thinning and inflammation decreased, and the best-corrected visual acuity improved from 6/24 to 6/9. Fortified amikacin eye drops (20 mg/mL) were continued until the fourth week, with no scleral thinning seen.

Conclusions

P. aeruginosa is a virulent organism that causes infectious scleritis complicated by melting and necrotizing of the sclera. This report emphasized that early recognition, intensive antimicrobial treatment, and surgical debridement can prevent morbidity related to this Pseudomonas infection.

Infectious Pseudomonas and Bipolaris scleritis following history of pterygium surgery

We report an interesting case of infectious scleritis from coinfection of Pseudomonas aeruginosa and Bipolaris with no corneal infiltrate. A healthy 60-year-old man with a history of infectious scleritis following pterygium excision presented with purulent material growing P. aeruginosa and 1+ colonies of Bipolaris species of fungus. Broad spectrum treatment was initiated with hourly topical moxifloxacin, fortified tobramycin, and natamycin along with a subconjunctival injection of voriconazole and topical cyclosporine, with PO ketoconazole. After 10 weeks of aggressive empiric treatment, the patient's symptoms had resolved, and his vision returned to baseline although a scleral patch graft was utilized to stabilize scleral thinning.

Ocular Pharmacology for Scleritis: Review of Treatment and a Practical Perspective

Scleritis is defined as an infectious or noninfectious inflammation of the sclera that can be broadly categorized according to anatomic location (ie, anterior or posterior) and whether the process is necrotizing or non-necrotizing. Treatment for scleritis is dictated by the etiology of the inflammation, with infectious forms requiring treatment of the inciting agent and noninfectious forms requiring treatment of the underlying inflammation with immunosuppression. Pharmacotherapy for noninfectious scleritis can be classified according to delivery route (eg, local or systemic) and mechanism of action (eg, biologic or nonbiologic). This review will briefly summarize the classification scheme for scleritis before reviewing in depth both systemic and local pharmacotherapies that can be used to effectively treat an eye afflicted by either infectious or noninfectious scleritis. Traditional anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs, steroids, and immunomodulatory therapy will be discussed, as well as newer biologic therapies such as antitumor necrosis factor alpha and anti-CD20 agents.

Candida albicans scleral abscess in a HIV-positive patient and its successful resolution with antifungal therapy-a first case report

Background

Fungal infection of the sclera is very rare. No case of fungal scleral abscess in a HIV-positive patient has been reported. We report a case of scleral abscess caused by Candida albicans and its successful resolution following antifungal therapy in a HIV-positive patient.

Findings

A 57-year-old diabetic Asian (Indian) who was on highly active antiretroviral therapy for the last 10 years presented with 2 weeks’ history of redness in his right eye. Examination revealed localised scleral inflammation with central ulceration in the inferior quadrant of the right eye. Initially, the ulcer scrapings revealed no microbial organism. Progression of ulcer although on empirical antibiotic therapy required repeat scrapings which showed Candida albicans species in culture sensitive to amphotericin and natamycin. Aggressive topical and systemic antifungals resulted in dramatic and complete healing of the ulcer in 3 weeks. Vision was well maintained at 20/30 throughout the treatment course, and the fundus remained normal.

Conclusions

This is the first ever case of fungal scleral abscess in a HIV patient to be reported emphasizing there is a need for high vigilance to suspect an infective aetiology of scleritis in patients with immunocompromised status. Prompt microbial assessment and appropriate antifungals can decrease morbidity in these unusual but serious cases as illustrated in this case.

Candida albicans scleral abscess in a HIV-positive patient and its successful resolution with antifungal therapy-a first case report

Background

Fungal infection of the sclera is very rare. No case of fungal scleral abscess in a HIV-positive patient has been reported. We report a case of scleral abscess caused by Candida albicans and its successful resolution following antifungal therapy in a HIV-positive patient.

Findings

A 57-year-old diabetic Asian (Indian) who was on HAART for the last 10 years presented with 2 weeks history of redness in his right eye. Examination revealed localised scleral inflammation with central ulceration in the inferior quadrant of the right eye. Initially, the ulcer scrapings revealed no microbial organism. Progression of ulcer although on empirical antibiotic therapy required repeat scrapings which showed C. albicans species in culture sensitive to amphotericin and natamycin. Aggressive topical and systemic antifungals resulted in dramatic and complete healing of the ulcer in 3 weeks. Vision was well maintained at 20/30 throughout the treatment course and the fundus remained normal.

Conclusions

This is the first ever case of fungal scleral abscess in an HIV patient to be reported emphasising there is a need for high vigilance to suspect an infective aetiology of scleritis in patients with immunocompromised status. Prompt microbial assessment and appropriate antifungals can decrease morbidity in these unusual but serious cases as illustrated in this case.

Biofilms of Pathogenic Nontuberculous Mycobacteria Targeted by New Therapeutic Approaches

Microbial infections of the cornea are potentially devastating and can result in permanent visual loss or require vision-rescuing surgery. In recent years, there has been an increasing number of reports on nontuberculous mycobacterial infections of the cornea. Challenges to the management of nontuberculous mycobacterial keratitis include delayed laboratory detection, low index of clinical suspicion, poor drug penetration, slow response to therapy, and prolonged use of antibiotic combinations. The ability of nontuberculous mycobacteria to evade the host immune response and the ability to adhere and to form biofilms on biological and synthetic substrates contribute to the issue. Therefore, there is an urgent need for new antimicrobial compounds that can overcome these problems. In this study, we evaluated the biofilm architectures for Mycobacterium chelonae and Mycobacterium fortuitum in dynamic flow cell chamber and 8-well chamber slide models. Our results showed that mycobacterial biofilms were quite resistant to conventional antibiotics. However, DNase treatment could be used to overcome biofilm resistance. Moreover, we successfully evaluated a new antimicrobial compound (AM-228) that was effective not only for planktonic mycobacterial cells but also for biofilm treatment and was compared favorably with the most successful “fourth-generation” fluoroquinolone, gatifloxacin. Finally, a new treatment strategy emerged: a combination of DNase with an antibiotic was more effective than an antibiotic alone.

Risk factors and clinical outcomes of bacterial and fungal scleritis at a tertiary eye care hospital

PURPOSE

The aim was to analyze demographics, risk factors, pathogenic organisms, and clinical outcome in cases with microbiologically proven bacterial or fungal scleritis.

MATERIALS AND METHODS

Retrospective review of all the medical records of patients with microbiologically proven infectious scleritis examined from March 2005 to December 2009 in the cornea services of L. V. Prasad Eye Institute, Hyderabad, India was done.

RESULTS

Forty-two eyes of 42 patients were included in this study. The mean age at presentation was 48.52 ± 14.10 years (range: 12-70). Surgery was the major risk factor seen in 24 eyes (58.5%). Scleral infection was noted after vitreoretinal surgery (with scleral buckle) in 15 eyes, cataract surgery in 3 eyes, pterygium surgery in 3 eyes, corneoscleral tear repair and scleral buckle surgery in 3 eyes. Sixteen eyes (39%) were on systemic or topical steroids at the time of presentation. History of injury was noted in 9 eyes (22%) and diabetes mellitus in 7 patients (17%). Associated keratitis was noted in 9 eyes (21.4%). The scleral abscess was unifocal in 33 eyes (78.5%), multifocal in 6 eyes (14.2%) and diffuse in 3 eyes (7.14%). The final follow-up ranged from 24 days to 37 months. The final visual acuity was better in 18 eyes (42.8%), stable in 13 (30.9%), and deteriorated in 7 eyes (16.6%). Recurrence was seen in 4 eyes (9.5%).

CONCLUSIONS

Surgery is a major risk factor for infectious scleritis in our series. Fungus was the most common organism isolated. Thorough debridement and intensive use of medications have improved the outcome.

Epidemiology and recurrence rate of pterygium post excision in Ghanaians

OBJECTIVES

To determine the epidemiology and recurrence rate of pterygium after excision using bare sclera technique.

DESIGN

Prospective non-comparative study.

SETTING

Ophthalmology unit, Korle-Bu Teaching Hospital, Accra, Ghana.

METHODS

The study involved 60 consecutive patients with primary apterygial from July 1998 to December 2000 who had bare sclera excision after informed consent. They were post-operatively followed up for 30-months.

RESULTS

Thirty-five patients (58%) were females. The patients' ages ranged from 17-75 years, mean (±12.6). Overall recurrence was 22(37%). The main complications encountered include were granuloma 20 %(n=12), restriction in medial rectus muscle motility 2(3%), persistent vascularisation at excision site 2(3%) and adherence leucoma with uveitis 1(2%). No significant association was found between recurrence and pterygium morphology, calcification, allergy and occupation (indoor or outdoor).

CONCLUSION

The recurrence rate after pterygium excision using bare sclera technique in Ghanaians is high (37%).

Nontuberculous Mycobacterial Ocular Infections: A Systematic Review of the Literature

Nontuberculous or atypical mycobacterial ocular infections have been increasing in prevalence over the past few decades. They are known to cause periocular, adnexal, ocular surface and intraocular infections and are often recalcitrant to medical therapy. These infections can potentially cause detrimental outcomes, in part due to a delay in diagnosis. We review 174 case reports and series on nontuberculous mycobacterial (NTM) ocular infections and discuss etiology, microbiology, risk factors, diagnosis, clinical presentation, and treatment of these infections. History of interventions, trauma, foreign bodies, implants, contact lenses, and steroids are linked to NTM ocular infections. Steroid use may prolong the duration of the infection and cause poorer visual outcomes. Early diagnosis and initiation of treatment with multiple antibiotics are necessary to achieve the best visual outcome.

Experience of scleritis and episcleritis at a tertiary center in Southern Taiwan

Purpose:

The purpose of this study was to review the clinical experiences of scleritis and episcleritis in Southern Taiwanese people during a 7-year period.

Methods:

The charts of 89 patients (representing 101 eyes) who had visited our clinic from January 2003 to July 2010 were retrospectively reviewed. They were diagnosed as having episcleritis or scleritis. The medical charts, slit lamp photographs, and laboratory data were reviewed. Age, gender, laterality, previous surgery history, systemic diseases, follow-up duration, and ocular complications were collected. The patients were classified as having clinically suspected noninfectious scleritis (CSNIS), clinically suspected infectious scleritis (CSIS), and episcleritis for analysis.

Results:

In the series of 89 patients (i.e., 101 eyes), 31 (34.8%; 32 eyes) patients had scleritis and 58 (65.2%; 69 eyes) patients had episcleritis. Episcleritis and scleritis occurred slightly more frequently in women than in men. In the 31 patients (32 eyes) diagnosed with scleritis, 12 (38.7%) patients had CSIS and 19 (61.3%) patients had CSNIS. Patients with scleritis were older than patients with episcleritis (p < 0.001). Previous pterygium excision was associated with CSIS and necrotizing scleritis.

Conclusion:

Scleritis occurred in a more elderly population. It was more frequently associated with ocular complications, compared to episcleritis. Both CSNIS and CSIS were associated with a history of pterygium excisional surgery. Our series of patients had a high occurrence of necrotizing scleritis. All cases of necrotizing scleritis were associated with a history of previous ocular surgery.

Infectious scleritis: clinical spectrum and management outcomes in India

In this retrospective case series, we studied the predisposing factors, causative organisms, clinical spectrum, and outcomes of 12 cases of culture-proven infectious scleritis. Nine of 12 patients had a history of preceding trauma (surgical or accidental). Past surgical history included small-incision cataract surgery (4), pterygium surgery (1), and trabeculectomy (1). Six patients had multifocal scleral abscesses due to Pseudomonas, Klebsiella, or Nocardia. Only 2 patients retained useful vision (>6/18). A poor visual acuity at presentation usually resulted in a worse visual outcome (P = 0.005). Four eyes developed phthisis. The addition of surgical intervention did not result in a significantly better visual outcome than medical management alone (P = 0.209), but resulted in a higher globe preservation rate (P = 0.045). Therefore, we concluded that infection must be ruled out in cases of scleritis with preceding history of trauma, and aggressive surgical intervention improves the anatomical outcome but does not change the visual outcome.

Clinical characteristics and visual outcomes in infectious scleritis: a review

Infection is a very important but rare cause of scleritis, occurring in about 5%-10% of all patients presenting with scleral inflammation. However, due to the similarity of its presentation, infectious scleritis is often initially managed as autoimmune, potentially further worsening its outcome. The overall visual outcome in infectious scleritis is generally worse than its autoimmune counterparts, perhaps because of the delay in diagnosis or because of the aggressive nature of associated microbes. Thus, there is a definite need for insight into the diagnostic approach and treatment options for this ocular disease process. Several studies and case reports have been published in recent years that have provided useful information regarding the presenting clinical features and etiologic microbial agents in infectious scleritis. This review summarizes the important findings in the literature that may aid in differentiating infectious scleritis from other etiologies, including predisposing factors, microbe-specific characteristics, diagnostic tools, treatment modalities, and outcomes.

Infectious scleritis mimicking severe ocular inflammation: atypical initial presentation

Two farmers presented with sudden-onset of severe conjunctival congestion and intense chemosis along with features of anterior uveitis. Intraocular pressure was elevated in the first case. Clinically, a diagnosis of severe ocular inflammation was made. Both were hospitalised and were started on topical and parenteral antibiotics. Subsequently, both presented with scleral abscess and choroidal detachment at the site of abscess. Scleral deroofing was performed which revealed fungal infection in the first and Pseudomonas aeroginosa in the second case. Both patients were treated accordingly and showed dramatic response with development of scarring and thinning along with complete resolution of choroidal detachment. Infective scleritis should be considered as one of the provisional diagnosis in patients presenting with features of unilateral ocular inflammation, especially in cases with history of trauma or in predisposed individuals.

Imaging studies in a case of infectious scleritis after pterygium excision

A 44-year-old woman presented with a painful red eye for 2 weeks. Ultrasound biomicroscopy and optical coherence tomography were instrumental in the diagnosis and management of this case of infectious scleritis associated with previous pterygium excision complicated by choroidal and retinal detachments.

Late-onset necrotizing scleritis due to pigmented mycetoma (dematiaceous fungi) in 2 cases

PURPOSE

To describe the atypical presentation of fungal infection and necrotizing scleritis, the potential role of histopathology in the diagnosis, and surgical excision in the management.

METHODS

Retrospective interventional case series.

RESULTS

Two patients presented with a pigmented conjunctival mass, one resembling necrotizing scleritis with uveal prolapse and the other resembling a pigmented ocular surface tumor, both after excision of nasal pterygium, 12 and 50 years previously, respectively. The pigmented lesion was 2 × 1.5 mm in each case, both situated on the bulbar surface 2 mm from the nasal limbus. After surgical excision, each lesion histopathologically displayed fungal filaments (pigmented dematiaceous fungi).

CONCLUSIONS

Pigmented mycetoma (dematiaceous fungi) can simulate uveal tissue prolapse, pigmented foreign body, or pigmented epibulbar tumors, particularly melanoma. Surgical excision of the entire lesion is effective for management.

Nontuberculous mycobacterial ocular and adnexal infections

The nontuberculous (also called "atypical") mycobacteria have become increasingly important causes of systemic as well as ocular morbidity in recent decades. All ocular tissues can become infected with these organisms, particularly in patients who are predisposed following ocular trauma, surgery, use of corticosteroids, or are immunocompromised. Because of their relative resistance to available antibiotics, multidrug parenteral therapy continues to be the mainstay of treatment of more serious ocular and adnexal infections caused by nontuberculous mycobacteria (NTM). Periocular cutaneous, adnexal, and orbital NTM infections remain rare and require surgical debridement and long-term parenteral antibiotic therapy. NTM scleritis may occur after trauma or scleral buckling and can cause chronic disease that responds only to appropriate antibiotic therapy and, in some cases, surgical debridement and explant removal. NTM infectious keratitis following trauma or refractive surgical procedures is commonly confused with other infections such as Herpes simplex keratitis and requires aggressive topical therapy and possible surgical debridement, particularly in those cases occuring after laser in situ keratomileusis. Only 18 cases of endophthalmitis due to NTM have been reported. Systemic and intraocular antibiotic therapy and multiple vitrectomies may be needed in NTM endophthalmitis; the prognosis remains poor, however. Disseminated NTM choroiditis in acquired immune deficiency syndrome patients with immune reconstitution during highly active anti-retroviral therapy is a rare infection that can present as a necrotizing chorioretinitis with dense vitritis, mimicking many other entities and needs to be recognized so that timely, life-saving treatment can be administered. Regardless of which ocular tissue is infected, all NTM ocular infections present similar challenges of recognition and of therapeutic intervention. We clarify diagnosis and delineate modern, effective therapy for these conditions.

Early surgical debridement in the management of infectious scleritis after pterygium excision

PURPOSE

The purpose of this study was to report outcomes of infectious scleritis after pterygium surgery, managed with antibiotic therapies and early scleral debridement.

METHODS

Retrospective chart review of 13 consecutive cases of infectious scleritis after pterygium excision between 1999 and 2009 was conducted. Collected data included prior medical and surgical history, latency period between pterygium surgery and presentation of infectious scleritis, culture and histopathologic findings, antibiotic regimen, length of hospital stay, visual acuity before and after treatment, and complications.

RESULTS

Median follow-up was at 14 months. Twelve patients underwent prompt surgical debridement after infectious scleritis diagnosis (median, 2.5 days). Debridement was delayed in one patient. Median hospital stay was 3 days. Best-corrected visual acuity improved in ten patients, remained stable in one patient, and decreased in two patients following treatment. Complications included scleral thinning requiring scleral patch graft (1/13), glaucoma (3/13), and progression to phthisis bulbi (1/13). No patients required enucleation.

CONCLUSIONS

In contrast to the generally poor outcomes in the literature, early surgical debridement of pterygium-associated infectious scleritis appears to offer improved prognosis.

Clinico-microbiological profile and treatment outcome of infectious scleritis: experience from a tertiary eye care center of India

Medical and microbiology records of seventeen patients (17 eyes), diagnosed as scleritis of infectious origin were reviewed; to study clinical features, predisposing risk factors, microbiologic profile and treatment outcome of infectious scleritis. The mean patient age was 52.3 ± 19.75 years. Twelve patients (70.6%) had history of trauma/prior surgery. Isolated organisms included Staphylococcus species (spp) (n = 5), Fungus (n = 4), Nocardia spp (n = 3), two each of atypical Mycobacterium spp and Streptococcus pneumoniae and one Pseudomonas aeruginosa. Treatment included intensive topical antimicrobial in all eyes and systemic medication in 15 (88.2%) patients; surgical exploration was needed for 13 (76.5%) patients and scleral patch graft was done in four (23.5%) patients. Lesions resolved in all patients and none required evisceration. The presenting log MAR visual acuity of 1.77 ± 1.40 and improved to 0.99 ± 0.91. (P ≤ 0.039) after treatment with a mean follow up of 22.57 ± 19.53 weeks. A microbiological confirmation, appropriate medical and/or surgical intervention has a good tectonic and visual outcome.

Management and outcome of microbial anterior scleritis

PURPOSE

To evaluate the prevalence, predisposing factors, and outcomes of bacterial and fungal scleritis.

METHODS

We reviewed the clinical findings, therapeutic interventions, and visual outcomes of patients with suppurative scleral inflammation without preceding microbial keratitis who had microorganisms isolated from scleral scrapings.

DESIGN

Retrospective interventional case series.

RESULTS

Of 349 patients with scleritis diagnosed from 1999 to 2009, 6 adults (1.7%) presented with suppurative inflammation of the anterior sclera due to Pseudomonas aeruginosa (2), Streptococcus pneumoniae (2), Staphylococcus aureus (1), and Scedosporium apiospermum/Pseudallescheria boydii (1). Each had ocular surgery of the affected eye before presentation. Intraocular extension occurred in 2 eyes. After local and systemic antimicrobial therapy, all improved without evisceration or enucleation, and 4 attained vision of 20/60 or better.

CONCLUSIONS

Bacterial or fungal scleritis is an uncommon ocular infection that can belatedly follow anterior segment procedures. Antimicrobial therapy and surgical intervention can successfully control progressive suppuration and reduce vision-limiting complications.

Nocardia scleritis-clinical presentation and management: a report of three cases and review of literature

Aim

This study aims to describe the clinical features and management of Nocardia scleritis.

Methods

The authors retrospectively reviewed medical charts of three patients with microbiologically proven Nocardia scleritis and reviewed literature.

Results

All the patients presented with areas of well-demarcated, circumscribed abscess. No specific clinical feature could be attributed to the causative organism. Nocardia was identified by smear and culture from the scleral exudates. The medical management was based on the antibiotic sensitivity. Surgical exploration of the suppurated area along with the healthy margins was done on all patients. Two patients required multiple explorations. All three patients resolved with a good visual and tectonic outcome. The literature review also suggests a good outcome with prolonged medical management though the preferred antibiotic has changed over the years.

Conclusion

Though the prevalence of a disease like Nocardia scleritis is low, the results suggest that specific diagnosis and appropriate management can lead to a good outcome.

Late-onset intrascleral dissemination of Stenotrophomonas maltophilia scleritis after pterygium excision

PURPOSE

To report a case of pterygium excision-related infectious scleritis with late-onset intrascleral dissemination.

METHODS

Case report.

RESULTS

A 72-year-old female patient was referred for Stenotrophomonas maltophilia scleritis after undergoing pterygium excision 18 years earlier. Surgical debridement and a tectonic corneal patch graft, along with conjunctival flap, were performed to repair the scleral defect after treatment with fortified topical and systemic antibiotics. However, intrascleral dissemination of scleritis occurred 5 months after the initial episode.

CONCLUSIONS

Intrascleral dissemination of S. maltophilia scleritis after pterygium excision might be delayed because of limited invasiveness and inherent resistance to several antibiotics. Long-term follow-up may be needed to protect against the possibility of late-onset intrascleral dissemination.