Posters

Case report: challenges in the management of a very aggressive post-operative fungal sclera-keratitis

Poster Details

First Author: A.Lula ALBANIA

Co Author(s):    R. Bulaj                    

Abstract Details

Purpose:

To report the clinical course of a very aggressive sclera-keratitis following surgical excision of pterygium with excessive application of cautery and adjunctive anti-proliferative agents, leading to a relatively avascular bed and creating favourable conditions for fungal or mycobacterial infections. Although intensive, topical and systemic, antifungal cover was applied, poor penetration of these medications into the avascular sclera impeded the treatment of this sight-threatening condition.

Setting:

University Hospital Centre Mother Theresa, Department of Ophthalmology, Tirana, Albania

Methods:

Case report of a 55 year old man presenting with pain and conjuctival injection in the right eye; peripheral corneal infiltrates and scleral necrosis confirmed the diagnosis of sclera-keratitis. A pterygium excision with excessive cautery and adjunctive anti-proliferative agents had been performed. Pseudomonas Aeruginosa was presumed as the causative agent; topical and systemic antibiotic treatment was initiated. A biopsy was sent for histopathology and microbiology analysis. Considering the ineffectiveness of the therapy, the antimicrobial regimen was re-considered; topical and systemic antifungal therapy was initiated. Due to deterioration of clinical manifestations and to prevent dissemination of the infection, enucleation was performed.

Results:

Despite the application of a multiple topical and systemic antibiotic treatment, the corneal infiltrates enlarged and the necrotic sclera deepened; although the antimicrobial regimen was re-considered to topical and systemic antifungal therapy, the corneal infiltrates and scleral necrosis worsened, while the patient started showing menacing visual hallucinations as a side effect of voriconazole. Therefore, enucleation was performed to prevent orbital and systemic dissemination of the infection and control of pain. After enucleation was performed, the pain completely resolved and major complications were avoided. The result from microbiology analysis confirmed “Scedosporium Prolificans” as the causative agent for this very aggressive sclera-keratitis.

Conclusions:

Although in the majority of cases with sclera-keratitis the most frequent infective cause is Pseudomonas Aeruginosa, fungal and mycobacterial agents should be taken into consideration. Additionally, intra-operative excessive application of cautery and adjunctive anti-proliferative treatment may lead to a relatively avascular scleral bed which would create favourable conditions for fungal or mycobacterial infections. An early consideration of these atypical causative agents is highly important; otherwise, despite an adequate intensive topical and systemic therapy, poor penetration of these medications into the avascular sclera would impede the treatment of this condition, leading to sight-threatening complications and menacing the integrity of ocular structures.

Financial Disclosure:

None