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Oh GJ, Khalili A, Hammersmith KM, Nagra PK, Rapuano CJ, Syed ZA. Determinants of Clinical Outcomes After Infectious Scleritis. Cornea 2023:00003226-990000000-00360. [PMID: 37647147 DOI: 10.1097/ico.0000000000003373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/25/2023] [Indexed: 09/01/2023]
Abstract
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.
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Affiliation(s)
- Glenn J Oh
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Ashley Khalili
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Cornea Service, Wills Eye Hospital, Philadelphia, PA; and
- Department of Ophthalmology, Northwell Health, Great Neck, NY
| | - Kristin M Hammersmith
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Cornea Service, Wills Eye Hospital, Philadelphia, PA; and
| | - Parveen K Nagra
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Cornea Service, Wills Eye Hospital, Philadelphia, PA; and
| | - Christopher J Rapuano
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Cornea Service, Wills Eye Hospital, Philadelphia, PA; and
| | - Zeba A Syed
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Cornea Service, Wills Eye Hospital, Philadelphia, PA; and
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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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Agarwal S, Pandey S, Srinivasan B, Anand AR, Iyer G. Possible Synergistic Role of Cryo-Alcohol Therapy in Infectious Scleritis-Scope and Rationale for Expanding Indications and Review of the Literature. Cornea 2023; 42:194-203. [PMID: 35249984 DOI: 10.1097/ico.0000000000003007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/10/2022] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Shweta Agarwal
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India ; and
| | - Sunita Pandey
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India ; and
| | - Bhaskar Srinivasan
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India ; and
| | - Appakkudal R Anand
- L and T Microbiology Research Centre, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - Geetha Iyer
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India ; and
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Thanathanee O, Charoensuk K, Uthairat Y, Laohapitakvorn S, Anutarapongpan O, Suwan-apichon O. Case Report: Burkholderia pseudomallei-Caused Sclerokeratitis. Am J Trop Med Hyg 2023; 108:293-295. [PMID: 36535255 PMCID: PMC9896322 DOI: 10.4269/ajtmh.22-0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/13/2022] [Indexed: 12/23/2022] Open
Abstract
This report is on a 45-year-old male patient without underlying disease who presented with a Burkholderia pseudomallei-caused keratoscleritis in his right eye. Slit-lamp examination revealed multiple, indistinct corneal infiltrations with subconjunctival/scleral abscesses. Corneal tissue culture was positive for B. pseudomallei and confirmed by mass spectrometry. The patient was treated with fortified ceftazidime, fortified gentamicin eyedrops, and intravenous ceftazidime injection. Penetrating keratoplasty, including intracameral ceftazidime injections, was undertaken due to corneal lesion worsening. Scleral debridement with subconjunctival ceftazidime injections were undertaken due to the progression of the scleral abscess. After 2 months, the corneal and scleral lesions were inactive, and the systemic and topical antibiotics were tapered. This is the first case report of B. pseudomallei-caused keratoscleritis with photography. The patient was seen in an endemic geographical area with multiple corneal infiltrations and subconjunctival/scleral abscess. Systemic and topical antibiotics accompanied with surgery should be considered.
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Affiliation(s)
- Onsiri Thanathanee
- Department of Ophthalmology, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Korawin Charoensuk
- Department of Ophthalmology, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Yuwarat Uthairat
- Department of Ophthalmology, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Suparat Laohapitakvorn
- Department of Ophthalmology, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Orapin Anutarapongpan
- Department of Ophthalmology, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Olan Suwan-apichon
- Department of Ophthalmology, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
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Abdelmegid O, Thakur S, Cheung AY. Nocardia arthritidis scleritis: A case report. Am J Ophthalmol Case Rep 2023; 29:101794. [PMID: 36686263 PMCID: PMC9851874 DOI: 10.1016/j.ajoc.2023.101794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/13/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Purpose This report describes a case and management of a 69-year-old female with infectious scleritis found to be caused by Nocardia arthritidis species. Observations Our patient presented with severe constant pain in the left eye (OS) following cataract surgery. She had a pertinent past medical history significant for renal transplantation (on oral tacrolimus, mycophenolate, and prednisone). Slit lamp examination OS (1 month after cataract surgery) demonstrated 3+ injection temporally accompanied by scleral thickening and multiloculated abscesses with purulent drainage from small conjunctival erosions. The abscesses were debrided and sent for gram stain and culture. The patient was treated with repeated subconjunctival injections of antibiotics and an antifungal; topical amphotericin, vancomycin, and amikacin; and oral trimethoprim-sulfamethoxazole (double strength). Two separate gram stains with cultures confirmed the diagnosis and species identification. The patient responded well to repeat subconjunctival injections early on in addition to the prescribed regimen, remaining free of disease at the last follow-up (12 months following presentation). Conclusions and Importance This unique case demonstrates infectious scleritis caused by an uncommon Nocardia species (N. arthritidis) that was successfully treated with similar strategies used for other reported Nocardia species. As Nocardia scleritis can lead to adverse outcomes if not treated promptly and properly, it should be considered on the differential diagnoses in an immunocompromised patient who presents with acute ocular symptoms after any recent ocular surgery.
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Affiliation(s)
- Omar Abdelmegid
- University of Massachusetts Medical School, Department of Ophthalmology, Worcester, MA, USA
| | - Shambhawi Thakur
- Eastern Virginia Medical School, Department of Ophthalmology, Norfolk, VA, USA
| | - Albert Y. Cheung
- Eastern Virginia Medical School, Department of Ophthalmology, Norfolk, VA, USA,Virginia Eye Consultants/CVP, Norfolk, VA, USA,Corresponding author. 241 Corporate Blvd., Norfolk, VA, 23502, USA.
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Shivaji S, Jayasudha R, Prashanthi GS, Arunasri K, Das T. Fungi of the human eye: Culture to mycobiome. Exp Eye Res 2022; 217:108968. [PMID: 35120870 DOI: 10.1016/j.exer.2022.108968] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 11/02/2021] [Accepted: 01/26/2022] [Indexed: 11/04/2022]
Abstract
The focus of the current review is multi-fold and compares the diversity and abundance of fungi on the ocular surface by the conventional culture-based method with the more sensitive, high throughput, culture-independent NGS method. The aim is to highlight the existence of a core ocular mycobiome and explore the transition of the ocular fungal microbiota from the normal eye to the diseased eye. PubMed, Google Scholar and Medline were used to search for publications and reviews related to cultivable fungi and the mycobiome of the normal and diseased eye. The conventional cultivable approach and the NGS approach confirm that the eye has its own mycobiome and several confounding factors (age, gender, ethnicity etc.) influence the mycobiome. Further, dysbiosis in the mycobiome appears to be associated with ocular diseases and thus impacts the health of the human eye. Considering that the mycobiome of the eye is influenced by several confounding factors and also varies with respect to the disease status of the eye there is a need to extensively explore the mycobiome under different physiological conditions, different ethnicities, geographical regions etc. Such studies would unravel the diversity and abundance of the mycobiomes and contribute to our understanding of ocular health. Research focused on ocular mycobiomes may eventually help to build a targeted and individualized treatment.
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Affiliation(s)
- Sisinthy Shivaji
- Prof. Brien Holden Eye Research Centre, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, 500034, India.
| | - Rajagopalaboopathi Jayasudha
- Prof. Brien Holden Eye Research Centre, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, 500034, India.
| | - Gumpili Sai Prashanthi
- Prof. Brien Holden Eye Research Centre, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, 500034, India.
| | - Kotakonda Arunasri
- Prof. Brien Holden Eye Research Centre, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, 500034, India.
| | - Taraprasad Das
- Srimati Kanuri Santhamma Centre for Vitreo Retinal Diseases, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, 500034, India.
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Yu J, Syed ZA, Rapuano CJ. Infectious Scleritis: Pathophysiology, Diagnosis, and Management. Eye Contact Lens 2021; 47:434-441. [PMID: 34224444 DOI: 10.1097/icl.0000000000000813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Julia Yu
- Cornea Service, Wills Eye Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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8
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Ranjith K, Sharma S, Shivaji S. Microbes of the human eye: Microbiome, antimicrobial resistance and biofilm formation. Exp Eye Res 2021; 205:108476. [PMID: 33549582 DOI: 10.1016/j.exer.2021.108476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND The review focuses on the bacteria associated with the human eye using the dual approach of detecting cultivable bacteria and the total microbiome using next generation sequencing. The purpose of this review was to highlight the connection between antimicrobial resistance and biofilm formation in ocular bacteria. METHODS Pubmed was used as the source to catalogue culturable bacteria and ocular microbiomes associated with the normal eyes and those with ocular diseases, to ascertain the emergence of anti-microbial resistance with special reference to biofilm formation. RESULTS This review highlights the genetic strategies used by microorganisms to evade the lethal effects of anti-microbial agents by tracing the connections between candidate genes and biofilm formation. CONCLUSION The eye has its own microbiome which needs to be extensively studied under different physiological conditions; data on eye microbiomes of people from different ethnicities, geographical regions etc. are also needed to understand how these microbiomes affect ocular health.
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Affiliation(s)
- Konduri Ranjith
- Jhaveri Microbiology Centre, Brien Holden Eye Research Centre, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India.
| | - Savitri Sharma
- Jhaveri Microbiology Centre, Brien Holden Eye Research Centre, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India.
| | - Sisinthy Shivaji
- Jhaveri Microbiology Centre, Brien Holden Eye Research Centre, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India.
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Agarwal R, Tripathi M, Kashyap S, Sharma S. Recalcitrant infective scleritis masquerading an autoimmune necrotising scleritis: a primary presentation of biopsy-proven granulomatosis with polyangiitis. BMJ Case Rep 2021; 14:e239517. [PMID: 33472807 PMCID: PMC10577764 DOI: 10.1136/bcr-2020-239517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 11/28/2022] Open
Abstract
Infectious scleritis is a rare but important cause of scleral inflammation. It is usually associated with an underlying ocular (prior ocular surgery or trauma) or systemic risk factor. A 53-year-old apparently systemically healthy woman presenting with spontaneous-onset pain, redness and watering in the left eye for 10 days was diagnosed with culture-proven Pseudomonas aeruginosa anterior scleritis. However, she was non-responsive to organism-sensitive antibiotics and scleral graft was performed twice, which showed graft re-infection. On repeated extensive systemic evaluations, the patient was diagnosed with biopsy-proven granulomatosis with polyangiitis (GPA). The patient was started on mycophenolate mofetil for both induction and maintenance phases and showed dramatic improvement with no recurrence till 1 year follow-up. High index of suspicion for autoimmune disorders, especially GPA, must be maintained for unilateral relentless infective scleritis masquerading as autoimmune necrotising scleritis. Mycophenolate mofetil holds a promising role for inducing as well as maintaining disease remission in ocular GPA.
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Affiliation(s)
- Rinky Agarwal
- Ophthalmology, All India Institute of Medical Sciences, New Delhi, India
| | - Manasi Tripathi
- Ophthalmology, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Kashyap
- Ocular Pathology, Dr RP Centre, All India Institute of Ophthalmic Sciences, New Delhi, India
| | - Sanjay Sharma
- Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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10
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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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12
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Concha Del Río LE, Ramirez-Dominguez C, Vanzzini-Zago V, Arellanes-Garcia L. Alternaria chartarum sclerokeratouveitis: A new fungus cause. Taiwan J Ophthalmol 2020; 11:190-192. [PMID: 34295628 PMCID: PMC8259522 DOI: 10.4103/tjo.tjo_17_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 02/10/2020] [Indexed: 11/16/2022] Open
Abstract
We report a case of Alternaria chartarum sclerokeratouveitis with an unfavorable response to treatment. To the best of our knowledge, there are no previous reports of this fungus invading the sclera. A 68-year-old diabetic farmer male patient presented with a 3-week history of pain and redness and a decrease in visual acuity occurring 5 days before admittance in the right eye. Examination revealed severe mixed hyperemia and a scleral calcified plaque with a surrounding area of ischemia and lysis. The cornea showed diffuse infiltrates, stromal edema, and hypopyon. Initial scrapings were negative, and empiric antibiotics were started. After a fungus was reported, topical and systemic antifungals were initiated, but there was no clinical response. The eye was enucleated. A slow-growing fungus A. chartarum, resistant to voriconazole, was isolated. Fungal etiology must be kept in mind when dealing with infectious scleritis. Despite treatment, the outcome of this case was unfavorable due to the slow-growing nature of the fungus and this strain's resistance to voriconazole.
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Affiliation(s)
- Luz Elena Concha Del Río
- Inflammatory Eye Diseases Clinic, Hospital Dr. Luis Sánchez Bulnes, Asociación Para Evitar La Ceguera En México, Mexico City, Mexico
| | - Carolina Ramirez-Dominguez
- Inflammatory Eye Diseases Clinic, Hospital Dr. Luis Sánchez Bulnes, Asociación Para Evitar La Ceguera En México, Mexico City, Mexico
| | - Virginia Vanzzini-Zago
- Inflammatory Eye Diseases Clinic, Hospital Dr. Luis Sánchez Bulnes, Asociación Para Evitar La Ceguera En México, Mexico City, Mexico
| | - Lourdes Arellanes-Garcia
- Department of Microbiology, Hospital Dr. Luis Sánchez Bulnes, Asociación Para Evitar La Ceguera En México, Mexico City, Mexico
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13
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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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