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Dutta Majumder P, Agarwal S, Shah M, Srinivasan B, K P, Iyer G, Sharma N, Biswas J, McCluskey P. Necrotizing Scleritis: A Review. Ocul Immunol Inflamm 2023:1-15. [PMID: 37279404 DOI: 10.1080/09273948.2023.2206898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
| | - Shweta Agarwal
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Mauli Shah
- Department of Uvea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Bhaskar Srinivasan
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Priyadarshini K
- Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Geetha Iyer
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Namrata Sharma
- Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jyotirmay Biswas
- Department of Uvea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Peter McCluskey
- Save Sight Institute, The University of Sydney, Sydney, Australia
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Karkhur S, Soni D, Sharma B. A novel technique of full-thickness scleral debridement in fulminant necrotising infectious scleritis and its outcomes-a consecutive case series. Int Ophthalmol 2021; 42:581-592. [PMID: 34613564 DOI: 10.1007/s10792-021-02030-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 09/22/2021] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Samendra Karkhur
- Retina, Uvea & ROP Services, Department of Ophthalmology, All India Institute of Medical Sciences (AIIMS), Saket Nagar, Bhopal, Madhya Pradesh, 462020, India.
| | - Deepak Soni
- Retina, Uvea & ROP Services, Department of Ophthalmology, All India Institute of Medical Sciences (AIIMS), Saket Nagar, Bhopal, Madhya Pradesh, 462020, India
| | - Bhavana Sharma
- Retina, Uvea & ROP Services, Department of Ophthalmology, All India Institute of Medical Sciences (AIIMS), Saket Nagar, Bhopal, Madhya Pradesh, 462020, India
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Lee SH, Kim JT, Lee MK, Jeong JH, Kim KW. Pseudallescheria boydii Necrotizing Scleritis Treated with Several Antifungal Agents. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2021. [DOI: 10.3341/jkos.2021.62.1.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ruiz-Lozano RE, Garza-Garza LA, Davila-Cavazos O, Foster CS, Rodriguez-Garcia A. The clinical and pathogenic spectrum of surgically-induced scleral necrosis: A review. Surv Ophthalmol 2021; 66:594-611. [PMID: 33422510 DOI: 10.1016/j.survophthal.2020.12.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Raul E Ruiz-Lozano
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico
| | - Lucas A Garza-Garza
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico
| | - Osvaldo Davila-Cavazos
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institute, Waltham, MA, USA; Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Alejandro Rodriguez-Garcia
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico.
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Karkhur S, Soni D, Sharma B. Necrotising fungal scleritis with full-thickness scleral melt and circumferential progression: a novel debridement approach. BMJ Case Rep 2020; 13:13/12/e237586. [PMID: 33372014 PMCID: PMC7772302 DOI: 10.1136/bcr-2020-237586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Samendra Karkhur
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Deepak Soni
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Bhavana Sharma
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Murthy SI, Sabhapandit S, Balamurugan S, Subramaniam P, Sainz-de-la-Maza M, Agarwal M, Parvesio C. Scleritis: Differentiating infectious from non-infectious entities. Indian J Ophthalmol 2020; 68:1818-1828. [PMID: 32823398 PMCID: PMC7690484 DOI: 10.4103/ijo.ijo_2032_20] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - S Balamurugan
- Department of Uvea, Aravind Eye Hospital, Pondicherry, India
| | | | | | | | - Carlos Parvesio
- Consultant Ophthalmologist, Moorfields Eye Hospital, Senior Lecturer, Biomedical Research Centre, Institute of Ophthalmology UCL Moorfields Eye Hospital, London, United Kingdom
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Agarwal M, Patnaik G, Sanghvi K, Anand AR, Janani MK, Biswas J. Clinicopathological, Microbiological and Polymerase Chain Reaction Study in a Case of Nocardia Scleritis. Ocul Immunol Inflamm 2020; 29:1496-1500. [PMID: 32634063 DOI: 10.1080/09273948.2020.1770299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To describe the clinicopathological, microbiological and polymerase chain reaction (PCR) study in a case of Nocardia scleritis. METHODS A retrospective chart review. RESULTS A 32-year old male presented with pain, redness and nodular scleral swelling in the left eye for the past two and a half months following an accidental rice powder injury. He was earlier diagnosed to have tubercular scleritis and treated with oral steroids and anti-tubercular therapy. A repeat scleral biopsy on histopathological examination showed granulomatous inflammation. Microbiological investigations revealed the growth of Gram +ve branching filamentous bacilli in culture suggestive of Nocardia sp. PCR based DNA sequencing identified the bacterium as Nocardia cyriacigeorgica. The patient responded to topical fortified amikacin (2.5%), fortified cefuroxime, oral sulfamethoxazole and trimethoprim with complete healing of scleritis. CONCLUSIONS Nocardia scleritis can be a diagnostic challenge for clinicians. Newer molecular techniques along with histopathological and microbiological investigations can clinch the diagnosis.
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Affiliation(s)
- Mamta Agarwal
- Uveitis & Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Gazal Patnaik
- Uveitis Services, Medical Research Foundation,Sankara Nethralaya, Chennai, India
| | - Kaushal Sanghvi
- Uveitis Services, Medical Research Foundation,Sankara Nethralaya, Chennai, India
| | - A R Anand
- L & T Microbiology Research Centre, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - M K Janani
- L & T Microbiology Research Centre, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - Jyotirmay Biswas
- Director of Uveitis & Ocular Pathology Department, Medical Research Foundation, Sankara Nethralaya, Chennai, India
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Park MH, Yoo WS, Kim HA, Chung I, Seo SW, Kim SJ. Clinical Features and Treatment Outcomes in Patients with Infectious Scleritis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2019. [DOI: 10.3341/jkos.2019.60.6.510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Mi-Hwa Park
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
| | - Woong-Sun Yoo
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Health Science Institute, Gyeongsang National University, Jinju, Korea
| | - Hyun-A Kim
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Health Science Institute, Gyeongsang National University, Jinju, Korea
| | - Inyoung Chung
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Health Science Institute, Gyeongsang National University, Jinju, Korea
| | - Seong-Wook Seo
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Health Science Institute, Gyeongsang National University, Jinju, Korea
| | - Seong-Jae Kim
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Health Science Institute, Gyeongsang National University, Jinju, Korea
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Guerrero-Wooley RL, Peacock JE. Infectious Scleritis: What the ID Clinician Should Know. Open Forum Infect Dis 2018; 5:ofy140. [PMID: 29977974 PMCID: PMC6016671 DOI: 10.1093/ofid/ofy140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/08/2018] [Indexed: 11/13/2022] Open
Abstract
Scleritis is an inflammatory process involving the outer coating of the globe which is characterized by focal or diffuse hyperemia, moderate to severe pain, and frequent impairment of vision. Most cases of scleritis are autoimmune in nature and are managed with topical and/or systemic corticosteroids. Infectious scleritis is a less common entity, occurring in 5%-10% of cases, and requiring directed antimicrobial therapy. We present a case of Nocardia farcinica anterior nodular scleritis diagnosed via positive culture of an excisional biopsy of a scleral nodule. The patient improved after combined surgical and medical therapy with amoxicillin-clavulanate and moxifloxacin for 12 months. Based on a literature review, a summary of reported cases of infectious scleritis is provided, and guidelines pertaining to diagnosis and management are offered.
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Affiliation(s)
- Richelle L Guerrero-Wooley
- Division of Infectious Diseases, Department of Medicine, Loma Linda University Medical Center, Loma Linda, California
| | - James E Peacock
- Division of Infectious Diseases, Department of Medicine, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
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Cunha LPD, Juncal V, Carvalhaes CG, Leão SC, Chimara E, Freitas D. Nocardial scleritis: A case report and a suggested algorithm for disease management based on a literature review. Am J Ophthalmol Case Rep 2018; 10:1-5. [PMID: 29780901 PMCID: PMC5956651 DOI: 10.1016/j.ajoc.2018.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 11/02/2017] [Accepted: 01/08/2018] [Indexed: 01/10/2023] Open
Abstract
Purpose To report a case of nocardial scleritis and to propose a logical treatment algorithm based on a literature review. Observations It is important to suspect a nocardial infection when evaluating anterior unilateral scleritis accompanied by multiple purulent or necrotic abscesses, especially in male patients with a history of chronic ocular pain and redness, trauma inflicted by organic materials, or recent ophthalmic surgery. A microbiological investigation is essential. In positive cases, a direct smear reveals weakly acid-fast organisms or Gram-positive, thin, beading and branching filaments. Also, the organism (usually) grows on blood agar and Lowenstein-Jensen plates. An infection can generally be fully resolved by debridement of necrotic areas and application of topical amikacin drops accompanied by systemic sulfamethoxazole-trimethoprim. Conclusions and significance Together with the case report described, we review data on a total of 43 eyes with nocardial scleritis. Our proposed algorithm may afford a useful understanding of this sight-threatening disease, facilitating easier and faster diagnosis and management.
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Affiliation(s)
- Laura Pires da Cunha
- Department of Ophthalmology and Visual Sciences, Escola Paulista de Medicina, Universidade Federal de São Paulo, Hospital São Paulo. 821, Botucatu Street, São Paulo, SP, Brazil
| | - Verena Juncal
- Department of Ophthalmology and Visual Sciences, Escola Paulista de Medicina, Universidade Federal de São Paulo, Hospital São Paulo. 821, Botucatu Street, São Paulo, SP, Brazil
| | - Cecília Godoy Carvalhaes
- Department of Microbiology, Immunology and Parasitology, Escola Paulista de Medicina, Universidade Federal de São Paulo. 715, Napoleão de Barros Street, São Paulo, SP, Brazil
| | - Sylvia Cardoso Leão
- Department of Microbiology, Immunology and Parasitology, Escola Paulista de Medicina, Universidade Federal de São Paulo. 862, Botucatu Street, São Paulo, SP, Brazil
| | - Erica Chimara
- Tuberculosis and Mycobacteriosis Service, Instituto Adolfo Lutz. 355, Dr Arnaldo Avenue, São Paulo, SP, Brazil
| | - Denise Freitas
- Department of Ophthalmology and Visual Sciences, Escola Paulista de Medicina, Universidade Federal de São Paulo, Hospital São Paulo. 821, Botucatu Street, São Paulo, SP, Brazil
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Stem MS, Todorich B, Faia LJ. Ocular Pharmacology for Scleritis: Review of Treatment and a Practical Perspective. J Ocul Pharmacol Ther 2017; 33:240-246. [PMID: 28355124 DOI: 10.1089/jop.2016.0127] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Maxwell S Stem
- 1 Associated Retinal Consultants P.C. , Royal Oak, Michigan
| | - Bozho Todorich
- 1 Associated Retinal Consultants P.C. , Royal Oak, Michigan
| | - Lisa J Faia
- 1 Associated Retinal Consultants P.C. , Royal Oak, Michigan.,2 Oakland University William Beaumont School of Medicine , Rochester, Michigan
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12
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Jeang LJ, Davis A, Madow B, Espana EM, Margo CE. Occult Fungal Scleritis. Ocul Oncol Pathol 2017; 3:41-44. [PMID: 28275602 DOI: 10.1159/000449103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/10/2016] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To heighten awareness of occult fungal scleritis. METHOD Case report and review of the literature. RESULTS A 73-year-old woman with diabetes mellitus was diagnosed for 3 months with immune-mediated scleritis and subsequently treated with corticosteroids. On referral, the patient had a scleral nodule with contiguous corneal infiltrate and hypopyon. Culture grew Fusarium species not further classified. The infection could not be controlled with antifungal therapy, and the eye was removed. No exogenous or endogenous source for the infection could be identified by clinical history or examination. CONCLUSION Fungal scleritis can develop in persons without a history of foreign body injury, minor trauma, or evidence of endogenous fungemia. A high index of suspicion for infectious scleritis must be maintained in persons with presumed immune-mediated scleritis who fail to respond to conventional therapy, particularly if they present with decreased visual acuity.
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Affiliation(s)
- Lauren J Jeang
- Department of Ophthalmology, Morsani College of Medicine, University of South Florida, Tampa, Fla., USA
| | - Aaron Davis
- Department of Ophthalmology, Morsani College of Medicine, University of South Florida, Tampa, Fla., USA
| | - Brian Madow
- Department of Ophthalmology, Morsani College of Medicine, University of South Florida, Tampa, Fla., USA
| | - Edgar M Espana
- Department of Ophthalmology, Morsani College of Medicine, University of South Florida, Tampa, Fla., USA; Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Fla., USA
| | - Curtis E Margo
- Department of Ophthalmology, Morsani College of Medicine, University of South Florida, Tampa, Fla., USA; Department of Pathology and Cell Biology, Morsani College of Medicine, University of South Florida, Tampa, Fla., USA
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Sharma H, Sudharshan S, Therese L, Agarwal M, Biswas J. Candida albicans scleral abscess in a HIV-positive patient and its successful resolution with antifungal therapy-a first case report. J Ophthalmic Inflamm Infect 2016; 6:24. [PMID: 27334612 PMCID: PMC4917511 DOI: 10.1186/s12348-016-0092-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 06/08/2016] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Hitesh Sharma
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, Tamil Nadu, India
| | - Sridharan Sudharshan
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, Tamil Nadu, India
| | - Lily Therese
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, Tamil Nadu, India
| | - Mamta Agarwal
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, Tamil Nadu, India
| | - Jyotirmay Biswas
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, Tamil Nadu, India. .,Uveitis and Ocular Pathology Department, Sankara Nethralaya, 18, College Road, Nungambakkam, Chennai, 600 006, India.
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14
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Candida albicans scleral abscess in a HIV-positive patient and its successful resolution with antifungal therapy-a first case report. J Ophthalmic Inflamm Infect 2016; 6:16. [PMID: 27207501 PMCID: PMC4875041 DOI: 10.1186/s12348-016-0083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 04/19/2016] [Indexed: 11/10/2022] Open
Abstract
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.
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Nodular Scleritis Associated with Herpes Zoster Virus: An Infectious and Immune-Mediated Process. Case Rep Ophthalmol Med 2016; 2016:8519394. [PMID: 27298747 PMCID: PMC4889796 DOI: 10.1155/2016/8519394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 04/26/2016] [Indexed: 12/30/2022] Open
Abstract
Purpose. To describe a case of anterior nodular scleritis, preceded by an anterior hypertensive uveitis, which was primarily caused by varicella zoster virus (VZV). Case Report. A 54-year-old woman presented with anterior uveitis of the right eye presumably caused by herpetic viral disease and was successfully treated. Two months later, she developed a nodular scleritis and started oral nonsteroidal anti-inflammatory without effect. A complete laboratory workup revealed positivity for HLA-B27; the infectious workup was negative. Therapy was changed to oral prednisolone and an incomplete improvement occurred. Therefore, a diagnostic anterior paracentesis was performed and the polymerase chain reaction (PCR) analysis revealed VZV. She was treated with valacyclovir and the oral prednisolone began to decrease; however, a marked worsening of the scleritis occurred with the reduction of the daily dose; subsequently, methotrexate was introduced allowing the suspension of the prednisolone and led to clinical resolution of the scleritis. Conclusion. This report of anterior nodular scleritis caused by VZV argues in favor of an underlying immune-mediated component, requiring immunosuppressive therapy for clinical resolution. The PCR analysis of the aqueous humor was revealed to be a valuable technique and should be considered in cases of scleritis with poor response to treatment.
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Reddy JC, Murthy SI, Reddy AK, Garg P. Risk factors and clinical outcomes of bacterial and fungal scleritis at a tertiary eye care hospital. Middle East Afr J Ophthalmol 2015; 22:203-11. [PMID: 25949079 PMCID: PMC4411618 DOI: 10.4103/0974-9233.150634] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Jagadesh C Reddy
- Department of Cornea, Anterior Segment and Refractive Surgery Services, Hyderabad, Andhra Pradesh, India
| | | | - Ashok K Reddy
- Department of Cornea, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Andhra Pradesh, India
| | - Prashant Garg
- Department of Cornea, Anterior Segment and Refractive Surgery Services, Hyderabad, Andhra Pradesh, India
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Shaikh SI, Biswas J, Rishi P. Nodular syphilitic scleritis masquerading as an ocular tumor. J Ophthalmic Inflamm Infect 2015; 5:8. [PMID: 25861399 PMCID: PMC4385283 DOI: 10.1186/s12348-015-0040-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/11/2015] [Indexed: 12/03/2022] Open
Abstract
Background Scleritis may be the initial or only presenting feature of systemic, autoimmune, or infectious disorders. Corticosteroids are the mainstay of treatment for immune-mediated scleritis. However, steroids could prove detrimental when used to treat infectious scleritis. Hence, infectious causes of scleritis should be ruled out. Findings A 47-year-old male from central India presented with swelling, pain, and redness in the left eye since 2 months. The patient was diagnosed elsewhere as having an extraocular extension of intraocular tumor and advised radiation brachytherapy for the same. Clinical examination revealed nodular scleritis in the left eye. The patient did not have any systemic illness or complaints suggestive of connective tissue disease. Laboratory investigations ruled out the same. However, Venereal Disease Research Laboratory (VDRL) test was positive. Rapid plasma reagin (RPR) test and Treponema pallidum hemagglutination assay (TPHA) were also positive, confirming the diagnosis of syphilis. Ultrabiomicroscopy (UBM) and ultrasound scan of the eye ruled out intraocular tumor. Treatment was initiated with benzathine penicillin 2.4 million units per week for 3 weeks to which the patient responded remarkably well. Conclusions Although rare, syphilis can present as nodular scleritis masquerading as ocular tumor. Syphilis must be considered in the list of etiological diagnoses in patients presenting with nodular scleritis, and testing for this disease should be a part of routine investigation in patients with scleritis.
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Affiliation(s)
- Sufiyan I Shaikh
- Shri Bhagwan Mahavir Vitreoretinal Services, 18, College Road, Sankara Nethralaya, Nungambakkam, Chennai, 600006, Tamil Nadu India
| | - Jyotirmay Biswas
- Uveitis & Ocular Pathology Department, Vision Research Foundation, 18, College Road, Nungambakkam, Chennai, 600006, Tamil Nadu India
| | - Pukhraj Rishi
- Shri Bhagwan Mahavir Vitreoretinal Services, 18, College Road, Sankara Nethralaya, Nungambakkam, Chennai, 600006, Tamil Nadu India
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Ramenaden ER, Raiji VR. Clinical characteristics and visual outcomes in infectious scleritis: a review. Clin Ophthalmol 2013; 7:2113-22. [PMID: 24235809 PMCID: PMC3821753 DOI: 10.2147/opth.s37809] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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.
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