Possible Synergistic Role of Cryo-Alcohol Therapy in Infectious Scleritis-Scope and Rationale for Expanding Indications and Review of the Literature.

PURPOSE: The purpose of this study was to highlight the use of topical ethanol as an adjunct to cryotherapy, termed cryo-alcohol therapy, in the management of fungal/acanthamoeba scleritis along with a review of the literature. METHOD: Retrospective interventional case reports of fungal and acanthamoeba scleritis along with a review of the literature. RESULTS: The patient with circumferential necrotic fungal scleritis resolved in 6 weeks achieving a best-corrected visual acuity (BCVA) of 20/20, and the patient with acanthamoeba scleritis is awaiting optical keratoplasty after complete resolution in 8 weeks. The literature review from January 1990 to December 2020 revealed BCVA >20/200 in 50% of the eyes with a mean time to resolution being 4.16 ± 2.13 months in fungal scleritis, with 27.02% and 75% of the eyes requiring evisceration in fungal and acanthamoeba scleritis, respectively. CONCLUSIONS: Cryotherapy is a useful adjunct in managing refractory infectious scleritis, and its efficacy can be enhanced by combining the use of topical ethanol to aid in faster recovery and reduce visual morbidity.

Enriched and Decreased Intestinal Microbes in Active VKH Patients.

Purpose: To determine the possible microbiome related to Vogt-Koyanagi-Harada (VKH) disease in comparison to patients with noninfectious anterior scleritis and healthy people. Methods: Fecal samples were extracted from 42 individuals, including 11 patients with active VKH, 11 healthy people, and 20 patients with noninfectious anterior scleritis. We amplified the V3 to V4 16S ribosomal DNA (rDNA) region to obtain the target sequence. Then, the target sequence was amplified by polymerase chain reaction. The obtained target sequences were sequenced by high-throughput 16S rDNA analysis. Results: At the genus level, there were three enriched (Stomatobaculum, Pseudomonas, Lachnoanaerobaculum) and two depleted (Gordonibacter, Slackia) microbes that were detected only in patients with VKH. There were 10 enriched and 12 depleted microbes that were observed in both patients with VKH disease and noninfectious anterior scleritis (P < 0.05). The interactions of these microbes were graphed. Tyzzerella and Eggerthella were the nodes of interaction between these microorganisms, which were regulated by both positive and negative aspects, but the expression level in patients with active VKH was upregulated. Conclusions: Special or nonspecial enrichment and decreased intestinal microbes were observed in patients with active VKH. The action mechanism of these microbes needs further study.

Fungal Necrotizing Scleritis After Intravitreal Injection Therapy.

PURPOSE: To report a case of infectious necrotizing scleritis secondary to Aspergillus terreus after intravitreal injection therapy. METHODS: This is a case report with literature review. RESULTS: A 98-year-old woman receiving intravitreal aflibercept injections for neovascular age-related macular degeneration in the left eye presented with severe pain, redness, and purulent discharge at the injection site. She was initially treated with topical fortified antibiotics, and clinical improvement was achieved, although microbial cultures showed negative results. Two months later, she presented with severe ocular pain and was diagnosed with anterior necrotizing scleritis. Scleral scrapings were collected for cultures, and intensive topical antibiotic therapy was reintroduced. Evaluation for autoimmune etiology and microbiological testing showed negative results. Because of the progression of the scleral necrotic area, empirical therapy with topical voriconazole was initiated, and surgical debridement was performed. Finally, the culture was positive for A. terreus. The modified therapy consisted of topical voriconazole and oral voriconazole for 3 months with an excellent clinical outcome. CONCLUSIONS: To our knowledge, this is the first case of fungal necrotizing scleritis secondary to intravitreal injection. Diagnosis was delayed due to its chronic clinical course and the slow fungal growth in culture media, but the combined medical and surgical approach resulted in a satisfactory outcome.

Clinicopathological, Microbiological and Polymerase Chain Reaction Study in a Case of Nocardia Scleritis.

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.

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

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

Severe ocular pain after anti-VEGF intravitreal injection / Dolor ocular severo tras inyección intravítrea con anti-VEGF

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Aspergillus Flavus Necrotising Scleritis following Pars Plana Vitrectomy.

PURPOSE: To report a case of fungal necrotising scleritis following pars plana vitrectomy. Results: A 65-year-old lady underwent phacoemlsificication with posterior capsular rupture and posteriorly dislocated lens in her left eye. On the same day she underwent 20 gauge pars plana vitrectomy and phacofragmentation. Postoperative period was uneventful for up to 6 weeks when she developed necrotising anterior scleritis with suppurative nodules. Scraping from the suppuration confirmed the presence of Aspergillus flavus. She was treated with topical Voriconazole and oral Itraconazole. Conclusion: We describe the first case of fungal necrotising scleritis without intraocular inflammation following pars plana vitrectomy (PubMed Search). Infection should be kept in the differential diagnosis of post-operative necrotising scleritis even in the absence of risk factors like hypopyon or diabetes. Early recognition improves final outcome. Medical therapy should be continued even after presumed cure to take care of residual fungi and prevent recurrences.

Can cryotherapy be used as an adjunct in select cases of recalcitrant endophthalmitis? - A case report.

We report two cases of recalcitrant endophthalmitis, a delayed postoperative fungal endophthalmitis following cataract surgery and an atypical mycobacterial endogenous endophthalmitis associated with infective scleritis. Due to recalcitrant nature of the endophthalmitis, one or more sittings of double freeze and thaw cryotherapy was applied over and adjacent to the infective foci in each case. This cryotherapy was used as an adjunct alongside conventional endophthalmitis management following which resolution of infection was observed in both cases.

Tubercular posterior scleritis: A case report and review of literature.

A 47-year-old female presented with optic disc oedema, peripapillary subretinal fluid and scattered areas of choroiditis. Her ultrasound B-scan showed sclerochoroidal thickening with widening of sub-Tenon space. Subsequent investigations revealed a positive Mantoux test and high-resolution computed tomography of the chest was suggestive of pulmonary involvement. She responded well to antitubercular treatment and systemic corticosteroid. A review of the literature was conducted to identify additional reports on similar cases and discussed. A high index of suspicion and appropriate laboratory work-up can aid in the diagnosis of tuberculous posterior scleritis.

A case report of infectious scleritis with corneal ulcer caused by Scedosporium aurantiacum.

RATIONALE: Scedosporium species is rare pathogen of ocular infection. The accurate diagnosis is delaying in many cases and the clinical prognosis is poor due to its resistance to antifungal agents. This report describes a patient with infectious scleritis and corneal ulcer caused by Scedosporium auranticum infection who required enucleation to control the infection. PATIENT CONCERNS: A 70-year-old woman visited our clinic after experiencing ocular discomfort in her right eye for 4 days after minor ocular trauma, with soil exposure. DIAGNOSES: Scedosporium species was isolated from a culture of corneal tissue, Scedosporium aurantiacum was identified in a culture of necrotic tissue. INTERVENTIONS: She was started on treatment with antifungal agents, including topical amphotericin B and systemic fluconazole, but her ocular condition did not improve. Although the lesion showed temporary improvement, ocular pain and corneal ulcer recurred 3 months later. Evisceration was performed due to corneal perforation, and enucleation was also performed for dehiscence of the conjunctiva and scleral necrosis. OUTCOMES: After enucleation, postoperative systemic voriconazole treatment controlled the infection without recurrence. LESSONS: S aurantiacum keratitis is difficult to eradicate, even with several months of treatment with systemic and topical antifungal agents, and tends to progress to scleritis. The infection can be terminated by the orbital enucleation. Infection with this rare organism should be included in the differential diagnosis of patients with severe infectious keratitis.

Presumed Tuberculous Sclerokeratitis Presenting with Hypopyon.

Purpose: To describe a case of presumed tuberculous sclerokeratitis which presented with anterior uveitis and hypopyon Methods: A retrospective chart review Results: A 23-year-old female presented with nodular scleritis, peripheral corneal opacities, and severe anterior chamber reaction with hypopyon. Her Mantoux test and interferon gamma release assay were positive and high-resolution computerized tomography of chest revealed right hilar lymphadenopathy. Aqueous aspirate from anterior chamber paracentesis of her right eye was negative for Mycobacterium tuberculosis genome. She responded to antitubercular treatment and oral corticosteroid Conclusions: Tuberculous sclerokeratitis can rarely present with hypopyon and pose a challenge in diagnosis for the clinicians.

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

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

Successful management of bee sting induced Aspergillus fumigatus endophthalmitis and scleritis.

Ocular bee stings are known to cause corneal melts, corneal infiltrates, cataracts, and secondary glaucoma. Our patient presented with scleritis, corneal infiltrates, and endophthalmitis after a ocular bee sting. Topical treatment led to resolution of anterior segment inflammation, but the scleritis and vitreous inflammation worsened. Vitrectomy with intravitreal antibiotics was done and scrapings from the scleral abscess showed growth of Aspergillus fumigatus on culture. Repeat vitrectomy with silicone oil was needed for retinal detachment. Oral and intravitreal antifungals led to resolution of inflammation with attached retina. This is the first reported case of bee sting-induced fungal endophthalmitis with scleritis.

Scedosporium apiospermum infectious scleritis following posterior subtenon triamcinolone acetonide injection: a case report and literature review.

BACKGROUND: Ubiquitous fungi of the Scedosporium apiospermum species complex (SASC) cause various opportunistic infections. Posterior subtenon triamcinolone acetonide (STTA) injection is a standard therapy for intraocular inflammation and macular edema. We report a case of Scedosporium apiospermum infectious scleritis after a posterior STTA injection. CASE PRESENTATION: A 75-year-old man received a posterior STTA injection to treat macular edema in his left eye. After 3 months, he complained of ocular pain and hyperemia in his left eye. Examination showed a subtenon abscess in the site corresponding with the STTA injection. After incising the abscess, the smear revealed numerous conidia-like structures. Although we suspected fungal infection and started topical voriconazole (VRCZ) and levofloxacin, the inflammation of the eye worsened. Fungal culture revealed filamentous fungus growth. Subsequently, we added systemic VRCZ and performed surgical debridement of the infected sclera and Tenon's capsule. Pathology of the sclera showed fungal hyphae. The antifungal susceptibility test revealed low minimum inhibitory concentrations for micafungin, VRCZ and miconazole (0.06, 0.25 and 0.5 µg/mL, respectively). After 2 months, the ciliary injection subsided and VRCZ therapy was stopped. However, subtenon abscess recurred 1 month after discontinuation of topical VRCZ. Surgical debridement and topical VRCZ were resumed, with the eye finally improving after 5 months of management. The fungal species was identified as Scedosporium apiospermum sensu stricto morphologically and by DNA sequencing. CONCLUSIONS: This case was successfully treated by topical and systemic VRCZ and repeated surgical debridement. Infectious scleritis caused by SASC rarely develops after posterior STTA. SASC can produce conidia in the enclosed subtenon space. Late-onset infectious scleritis after a posterior STTA injection suggests the presence of a fungal infection, including SASC, thereby requiring extensive and prolonged medical and surgical treatment.

Surgical treatment of Metarhizium anisopliae sclerokeratitis and endophthalmitis.

A 55-year-old nurse was referred with a 5-month history of right eye corneal abscess. The initial injury occurred when doing lawn work. The infection worsened despite multiple antibiotic, antiviral, and steroid treatments. Visual acuity was limited to hand motion. On examination, there was keratitis, ocular hypertension, and a secondary cataract. Corneal scrapings grew a filamentous fungus, identified as Metarhizium anisopliae (MA). Despite intensive antifungal treatment with topical, intravitreous, and systemic voriconazole, purulent corneal melting and scleritis with endophthalmitis rapidly appeared. An emergency surgical procedure including sclerocorneal transplantation, cataract surgery, a pars plana vitrectomy using temporary keratoprosthesis, and scleral crosslinking was necessary. One year after the surgery, there was no recurrence of infection. Functional outcome remained very poor. This is the first case of sclerokeratitis and endophthalmitis caused by MA ever reported. The infection was successfully treated with an aggressive combination of medical and surgical treatments.

Tuberculous scleral abscess with choroidal detachment.

We present a case of ocular tuberculosis (TB) presenting as scleral abscess with choroidal detachment. A 60-year-old woman presented with intense pain, redness, watering and decreased vision in the right eye (RE) for 1 week duration. Slit lamp examination of RE revealed diffuse scleritis with two pus-pointing areas in the supero-temporal quadrant suggesting scleral abscess. Fundus examination of the RE showed choroidal detachment in the temporal and inferior quadrant. Left eye examination was unremarkable. Ziehl-Neelsen staining of scleral biopsy showed acid-fast bacilli. PCR of the scleral tissue was also positive for Mycobacterium tuberculosis genome. The final diagnosis of tuberculous scleral abscess with choroidal detachment was made and patient showed good response to antitubercular treatment. In countries endemic for TB, it should be considered as a differential diagnosis for scleral abscess, since prompt diagnosis and treatment will ensure good visual outcome as depicted in our case.

Infectious Pseudomonas and Bipolaris scleritis following history of pterygium surgery.

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