Cornea Cases

Title:

A novel cause of infectious keratitis occurred in the context of severe ocular surface disease

Case Report Details

First Author: C.Bonzano ITALY

Co Author(s):    C. Bonzano   C. Cutolo   C. Pizzorno   R. Scotto   C. Traverso        

Abstract Details

Purpose:

To report the management of Candida Pararugosa, a new yeast responsible for infectious keratitis in a patient affected by systemic scleroderma

Setting:

Clinica Oculistica, Di.N.O.G.M.I. University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy.

Report of case or case series:

A 79-year-old Caucasian female presented to our cornea service complaining about a painful decrease in vision in both eyes for the past seven days. Our first evaluation revealed a corneal perforation in her right eye and a sterile corneal ulcer in her left eye. Her medical history was positive for glaucoma on topical medication, age-related macular degeneration in both eyes, and systemic scleroderma. The patient was managed by applying cyanoacrylate glue and a bandage contact lens in the right eye, topical autologous serum q6h and bandage contact lens in her left eye, on topical antibiotics, and preservative-free artificial tears q2h. Antiglaucoma medication was switched to oral acetazolamide. Two months later, the glue in the right eye got dislodged and the anterior chamber remained quiet and deep. Five days later, the slit-lamp examination revealed a temporal-inferiorly deep whitish corneal infiltrate with a satellite lesion, an inferior hypopyon of 2.0 mm, and mild corneal edema. Corneal scraping resulted negative for bacteria. Based on the clinical appearance, empiric antifungal therapy with fluconazole 10mg/ml eye drop solution q2h was started. Despite the therapy, we observed a clinical worsening. Confocal microscopy was suggestive for yeast, and the lab confirmed the presence of Candida Pararugosa. The patient was started on topical voriconazole 1% every hour. Subconjunctival and intrastromal voriconazole injections (50 μg/0.1 ml) were performed, and the cornea lesion improved in the following weeks.

Conclusions/Take Home Message:

Corneal ulceration and perforation may occur in the course of severe systemic scleroderma. Topical antiglaucoma medications may worsen the ocular surface disease; lowering intraocular pressure with oral acetazolamide or laser trabeculoplasty should be preferred in this case. Cyanoacrylate glue is useful for the closure of impending or small size corneal perforations; after its application, stromal neovascularization frequently affects the corneal healing response. Secondary microbial infiltrates can develop, especially when the contact lens and glue are in place for longer than six weeks, so a strict follow-up must be maintained. Candida Pararugosa is an unusual yeast infection, and it has never been isolated in the human cornea before. Voriconazole proved to be effective against this challenging infectious keratitis. Adding subconjunctival and intrastromal voriconazole injections to topical drops could significantly increase the healing rate and fasten the deep fungal keratitis resolution.