Fulminant scleral abscess secondary to infected scleral buckle with Moraxella species.

We here report a case of scleral buckle infection with fulminant scleral abscess secondary to Moraxella species. A 54-year-old chronic alcoholic male with a history of retinal detachment repair, with scleral buckle 8 years prior, presented with complaints of severe pain, redness, and swelling in the right eye since 2 weeks. The patient was diagnosed with scleral buckle infection, the buckle was removed, and cultures revealed Moraxella species. The postoperative course included fulminant scleral abscess treated with dual antibiotic therapy that included ceftriaxone and moxifloxacin. All systemic antibiotics were discontinued after 3 weeks, retina remained attached, and no recurrence occurred over a 1-year follow-up. Moraxella, though commonly associated with bacterial keratitis, can also lead to buckle infection, especially in chronic alcoholic and immunocompromised patients. In buckle infection, infected buckle along with sutures should be immediately removed without damaging underlying compromised sclera. Lastly, culture and drug sensitivity play a very important role in buckle infections.

Mycobacterium chelonae Scleral Abscess After Intravitreal Ranibizumab Injection.

PURPOSE: To report a case of Mycobacterium chelonae scleral abscess after an intravitreal injection of ranibizumab. METHODS: A 54-year-old female received an intravitreal ranibizumab injection for diabetic macular edema. Two weeks postinjection, a scleral abscess developed at the injection site. The patient was treated with incision and drainage of the abscess, subconjunctival injection of amikacin, topical clarithromycin and amikacin, and oral clarithromycin. RESULTS: After 4 weeks of treatment, the inflammation and infection resolved, and the patient returned to best-corrected preinjection visual acuity. CONCLUSIONS: Injection-site scleral abscesses are very rare and serious complications of intravitreal injections. Once the abscess is drained, it is possible to identify the organism and treat the infection with appropriate combination antibiotic therapy.

Prophylactic removal and microbiological evaluation of calcified plaques after pterygium surgery.

PURPOSE: The aim of this study was to investigate microbiological characteristics of prophylactically removed calcified plaques developed after pterygium excision, and to evaluate risk factors for the growth of microorganisms. METHODS: Only exposed calcified plaques developed at the same site of previous pterygium excision were prospectively removed in 15 eyes of 14 patients. Plaques were completely removed, divided into small pieces and evaluated for microbiological identification. Underlying scleral defects were reconstructed using a conjunctival autograft, amniotic membranes and scleral patch grafts according to the size and depth of the defects. Based on the results of microbiologic cultures, eyes were divided into two groups and risk factors for microbial growth were analyzed. RESULTS: At surgery, the mean age of the patients was 71.2 ± 5.8 years and 71.4 % were females. The mean time interval between pterygium excision and calcified plaque removal was 19.3 ± 13.8 years. Six of 15 (40 %) removed plaques showed bacterial growth, and Stenotrophomonas maltophilia was the most frequently isolated microorganism. The size of calcified plaques was the only risk factor for culture-positive results (p = 0.045). Underlying scleral defects were successfully repaired without any serious complication. CONCLUSIONS: Microorganisms can be isolated from calcified plaques developed at the site of previous pterygium excision, and the size of plaques is the only risk factor for culture-positive results. To remove potential source of infection, prophylactic removal of calcified plaques and scleral surface reconstruction should be considered, especially when the plaques are exposed and large.

Fungal scleritis with exudative retinal detachment.

PURPOSE: To report a case of fungal scleritis associated with exudative retinal detachment. DESIGN: A rare case report. METHODS: Nonresolving fungal scleritis mimicking noninfective scleritis was treated with systemic and topical antifungals and low topical steroids after diagnosis was established on scleral scraping. Even after complete resolution of scleritis, exudative retinal detachment persisted. RESULTS: The patient was advised of a possible need to undergo vitreo retinal surgery if exudative retinal detachment persisted for more than a month after complete resolution of the scleritis component. CONCLUSION: Infective scleritis must be ruled out in cases of longstanding scleritis not responding to immunosuppressives.

Vibrio vulnificus endophthalmitis occurring after ingestion of raw seafood.

Ocular Vibrio vulnificus infections are quite rare, and all previously reported cases have been associated with exposure to seafood and seawater. Here, we report a case of endogenous endophthalmitis caused by V. vulnificus, occurring after the ingestion of raw seafood. This case was not associated with any cutaneous or other severe systemic manifestations.

Scleral ulceration caused by Cryptococcus albidus in a patient with acquired immune deficiency syndrome.

PURPOSE: To describe a case of a scleral ulceration caused by Cryptococcus albidus in a patient with acquired immune deficiency syndrome (AIDS). DESIGN: Interventional case report. A 16-year-old girl with AIDS was admitted to the hospital with a 1-week history of cough, fever, and sudden onset of a painless scleral lesion on her left eye. Culture of the lesion revealed the fungus Crypotococcus albidus. RESULTS: The patient was treated with topical amphotericin B and systemic itraconazole, and she recovered fully over 4 weeks without sequelae. CONCLUSION: Cryptococcus albidus rarely causes disease in humans. It should be considered as a potential cause of ocular and systemic disease in patients with AIDS.

Case of a large, movable bacterial concretion with biofilm formation on the ocular surface.

OBJECTIVE: To report a case with a large movable bacterial concretion formed on the ocular surface without biomaterials. METHODS: Interventional case report. A 74-year-old woman with left eye pain and injection was referred to us. She had a past history of scleral patch graft for necrotizing scleritis after pterygium removal and mitomycin C instillation on her left eye 7 years before. On present examination, a 2.5- to 3.0-mm yellowish-white calcification-like mass was present on the nasal sclera and cornea, and it moved slightly with blinking. The anterior chamber was shallow, and cornea was suspected to be perforated under this object. RESULTS: This yellowish-white mass was surgically removed. Pathologic examination demonstrated that the specimen was not a calcification but a biofilm formation by many gram-positive bacilli with neutrophils. Corynebacterium was highly suspected as the causative agent of this unusual mass because of the earlier culture of the discharge before referral. CONCLUSION: The current case demonstrates that bacterial biofilms can be formed on the ocular surface without the involvement of biomaterials.

Recurrent scleral abscess after uncomplicated cataract extraction.

PURPOSE: To report the unusual occurrence of a recurrent scleral abscess after uncomplicated cataract extraction. METHODS: Case report of a 77-year-old healthy woman. RESULTS: Multiple cultures and antibiotic treatments failed to resolve presenting symptoms. Gram stain, Gomori methenamine silver (GMS) stain, and all cultures were negative. After drainage of the abscess, the patient's symptoms cleared briefly, then returned 6 months later showing a positive GMS stain consistent with Candida. The patient was treated with amphotericin, natamycin, and fluconazole at this time, and a return in visual acuity occurred along with a resolution of symptoms. No re-occurrence has been noted with 2.5 years of follow-up. CONCLUSIONS: Cataract extraction, although generally a safe procedure, can still result in unusual complications such as scleral abscesses. Excellent outcomes are possible once the infections are identified and treated.

Tuberculous granuloma managed by full thickness eye wall resection.

PURPOSE: To report the use of eye wall resection in the management of tuberculous granuloma. DESIGN: Interventional case report. METHODS: In a 26-year-old man with biopsy-proven tuberculous granuloma of the left eye, total eye wall resection and donor scleral grafting was performed for management of tuberculous granuloma involving the sclera, part of the cornea, the iris, the chamber angle, and the ciliary body. Adjuvant therapy included oral antitubercular medication. RESULTS: The treatment of the infection was successful. The scleral graft healed well, and the crystalline lens was preserved. CONCLUSIONS: Total eye wall resection, a technique described in the management of uveal tumors, can be adopted to manage selected cases of tuberculous granuloma of the eye.

Amniotic membrane graft for the management of scleral melting and corneal perforation in recalcitrant infectious scleral and corneoscleral ulcers.

PURPOSE: To study the efficacy and safety of using cryopreserved human amniotic membrane (AM) graft as a patch graft to reduce stromal melting and promote reepithelialization in extensive infectious scleral and corneoscleral ulcers. METHODS: Four cases of infectious scleral ulcers with persistent scleral melting and no sign of reepithelialization and three cases of corneoscleral ulcers with corneal perforation were studied. All patients had previously undergone pterygium excision, and infections were caused by Pseudomonas (n = 4), fungi (n = 2), and atypical Mycobacterium (n = 1). The area of limbus involved ranged from 3 to 9 (mean, 4.7) o'clock positions. Repeated debridements were performed, the causative microorganisms were identified, and the appropriate topical and systemic antibiotics were given to all patients before AM grafting. Postoperatively, the speed of reepithelialization, changes in the severity of scleral melting and inflammation, recurrence of infection, and visual acuity were documented. RESULTS: Melting and inflammation at the lesion site decreased after AM grafting. Reepithelialization of the scleral lesions was complete at an average 15.7 +/- 8.7 days (range, 5-31) postoperatively. Focal melting of the AM graft occurred in two cases, and in one case, it was necessary to perform further corneoscleral graft. No recurrent infection was encountered, but sterile abscess occurred in three cases that were located away from the original lesion. Useful vision above 20/400 was maintained in all patients at the end of follow-up. CONCLUSION: The AM graft is effective in promoting conjunctival reepithelialization and reducing scleral melting and inflammation and can be considered as an alternative biomaterial to improve wound healing in scleral and corneoscleral ulcerations.

Conjunctival rhinosporidiosis associated with scleral melting and staphyloma formation: diagnosis and management.

PURPOSE: Although conjunctival rhinosporidiosis is endemic in India, associated scleral melting and staphyloma formation are quite rare. We report clinical features and management in three patients with this unusual presentation. METHODS: Retrospective review of case records of three patients with conjunctival rhinosporidiosis. RESULTS: Infection occurred in young, healthy adults and was localized to the forniceal conjunctiva in all patients. The affected conjunctiva had numerous grey-white spherules, but a polyp-like lesion was not present in any patient. Diagnosis was based on clinical features and examination of scrapings from the involved conjunctiva. Treatment was surgical, with excision of infected conjunctival tissues and staphyloma repair with homologous sclera or autogenous periosteum. Failure to recognize the conjunctival pathology in one patient resulted in recurrence of the staphyloma. CONCLUSION: Conjunctival rhinosporidiosis can be associated with scleral staphyloma in young, healthy, adults. Differentiating this entity from idiopathic scleral ectasia requires knowledge of the clinical features of conjunctival rhinosporidiosis and a high index of clinical suspicion.

Intrascleral dissemination of infectious scleritis following pterygium excision.

AIMS: To assess the clinical pictures, possible pathogenesis, management, and therapy of patients with infectious scleritis associated with multifocal scleral abscesses following pterygium excision. METHODS: The records of patients with infectious scleritis after pterygium excision who developed multifocal scleral abscesses presenting from 1988 to the end of 1995 were reviewed. Early culture of abscesses was performed, and topical, systemic antimicrobials, or both were given to all patients. Fourteen eyes were operated on in addition to antimicrobial treatment. RESULTS: The initial culture reports of scleral ulcers identified Pseudomonas species in 12 of these 18 patients, Aspergillus in one, Mycobacterium fortuitum in one, and mixed organisms in four. Subsequent abscess cultures were taken from 15 of the infected eyes, and revealed the same organism as the initial culture in 12. Associated complications included four serous retinal detachments, three choroidal detachments, two double detachments, five complicated cataracts, and four recurrences of the initial infection. Four eyes required eventual enucleation and 11 eyes regained useful vision. CONCLUSIONS: With subsequent abscess cultures proving to be the same organism as found in the initial ulcer, the abscess formation appears to represent intrascleral dissemination. Early diagnosis and appropriate, prolonged topical plus systemic antimicrobial treatment are essential to halt the progression of such severe infections.

Clinical experiences of infectious scleral ulceration: a complication of pterygium operation.

AIMS: To report the special clinical manifestations and determine the appropriate management of infectious scleral ulceration. METHODS: A retrospective study was performed on 30 eyes with infectious scleral ulceration. Information was recorded on patients' age, onset and course of disease, pathogenic organism, clinical presentations, methods of diagnosis, treatment, and outcome. RESULTS: 10 cases (33.3%) were accompanied by corneal involvement. Subconjunctival abscess was noted in 16 cases (53.3%). 17 cases (56.7%) gave positive results of pathogen culture and all were Pseudomonas aeruginosa. Two cases had combined bacterial infections and one case was complicated by fungal infection. A total of 26 cases had surgical debridement in this series. Extensive involvement of the sclera with the presence of a 'tunnel lesion' or a 'satellite subconjunctival abscess' were found during debridement. All of the eyeballs involved were salvaged except one. CONCLUSION: The results of this study were contrary to the poor prognosis presented in previous reports. Early and repetitive surgical debridement is believed to be mandatory in the intractable cases to shorten the admission period and to save these eyes.

Repair of a giant scleral ulcer with preserved sclera and tissue adhesive.

BACKGROUND AND OBJECTIVE: Infectious scleral ulcer is a rare but severe late complication of pterygium surgery. Scleral grafts may be required in scleral ectasia with uveal exposure, corneal distortion, and severe anterior chamber reaction that are induced by scleral ulcer. The authors report a method for scleral grafting with preserved sclera and tissue adhesive. PATIENTS AND METHODS: Six cases of infectious scleral ulcers were repaired with this method. Preserved sclera was attached to the thinning sclera with tissue adhesive without sutures. The free or rotation conjunctival flap was placed over the graft area and sutured with 10-0 nylon. RESULTS: The six cases repaired by this method showed good results during the follow-up, except for one loss. The only complication was protrusion of the adhesive postoperatively. This protrusion can be easily removed with forceps on an outpatient basis. CONCLUSION: Tissue adhesive with preserved sclera is a useful method for repair of scleral thinning.

Scleral necrosis and infection 15 years following pterygium excision.

Scleral necrosis and infection are serious late complications of pterygium treatment and are difficult to manage. We describe a 70-year-old Chinese male who presented with scleral necrosis and Pseudomonas aeruginosa infection 15 years after the excision of a pterygium. The infection was treated early and aggressively with intensive topical and intravenous antibiotics and the thin necrotic sclera was reinforced with a donor scleral patch graft when the scleral infection was clinically controlled. The integrity of the globe was maintained by a thin layer of sclera anterior to the graft after the graft gradually shrunk in size and retracted posteriorly. The eye was saved from possible scleral perforation and endophthalmitis. This case is reported to highlight the importance of early aggressive treatment of infection and the value of prophylactic repair of scleral necrosis in the management of these late complications of pterygium treatment.