Atypical fungal sclerokeratitis.

PURPOSE: To report a case of fungal sclerokeratitis caused by Metarrhizium anisopliae, which to our knowledge is the first reported case worldwide. METHODS: A 52-year-old woman presented from rural Australia with a 1-week history of ocular injection involving the right eye without associated pain. Her best-corrected visual acuity was 6/9 in the right eye and 6/6 in the left eye. Intraocular pressure was 40 and 15 mm Hg in the right eye and left eye, respectively. On examination, a 7.0 x 4.5-mm area of corneal infiltrate and adjacent scleral necrosis involving the nasal limbus was evident. Cultures of corneal scrapings grew a filamentous fungus, identified as Metarrhizium anisopliae. The patient was started on multiple antifungal agents including topical natamycin, systemic and topical voriconazole, and eventually systemic and topical posaconazole. RESULTS: No significant response to antifungal agents over the course of a 25-day hospital admission was seen. A limbus-to-limbus therapeutic corneal graft was performed on eventual perforation. The patient developed multiple postoperative complications including cataract, hypotony, and a flat anterior chamber. Six months after initial presentation, her resulting visual acuity was hand motion, with evidence of early graft failure and hypotony; however, she was free of infection. CONCLUSIONS: Metarrhizium anisopliae is an extremely rare cause of ocular infection, and this report represents the first case of sclerokeratitis caused by this pathogen worldwide. Although found to be clinically sensitive to antifungal agents in previously reported cases of keratomycosis alone, it was found to be resistant to multiple antifungal agents with devastating consequences with the presence of scleral involvement.