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   Table of Contents      
CASE REPORT
Year : 1998  |  Volume : 46  |  Issue : 4  |  Page : 251-252

Effect of topical 0.02% polyhexamethylene biguanide on Nocardial keratitis associated with scleritis


Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, India

Correspondence Address:
N Venkatesh Prajna
Aravind Eye Hospital and P G Institute of Ophthalmology, 1 Anna Nagar, Madurai - 625 020
India
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Source of Support: None, Conflict of Interest: None


PMID: 10218310

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How to cite this article:
Prajna N V, Anitha M, Divya R, George C, Srinivasan M. Effect of topical 0.02% polyhexamethylene biguanide on Nocardial keratitis associated with scleritis. Indian J Ophthalmol 1998;46:251-2

How to cite this URL:
Prajna N V, Anitha M, Divya R, George C, Srinivasan M. Effect of topical 0.02% polyhexamethylene biguanide on Nocardial keratitis associated with scleritis. Indian J Ophthalmol [serial online] 1998 [cited 2019 Sep 16];46:251-2. Available from: http://www.ijo.in/text.asp?1998/46/4/251/24174

Ocular manifestation of Nocardial infection is rare and can present as keratitis, chronic keratoconjunctivitis, chronic orbital infection, chorioretinitis, endophthalmitis, dacryocystitis, and scleritis. These lesions can occur in isolation or in combination. Numerous treatment modalities have been tried for Nocardial keratitis with varying response. We present a case of Nocardial keratitis associated with scleritis, successfully treated with 0.02% polyhexamethylene biguanide (PHMB).


  Case Report Top


A 28-year-old male patient presented to us with complaints of pain and irritation for 2 weeks in the left eye. He described a history of trauma to the left eye, with straw, just before the onset of symptoms. Prior to the presentation at the hospital, he had instilled human milk and some herbal juice for 4 days. On examination, the left eye showed moderate lid edema and diffuse congestion of the conjunctiva. A 3.5x2.5 mm ulcer was found located just below the centre of the cornea with deep stromal infiltration. A1 mm hypopyon was present. Scrapings of the ulcer were taken with a flamed sterile Kimura's spatula and examined using 10% potassium hydroxide and Gram's stain. Material from the ulcer was also inoculated onto sheep blood agar and potato dextrose agar. Both the smears revealed delicate branching filaments which were gram positive. An acidfast preparation was made using a modified Kinyouns staining method which revealed pink branching filaments with overlying granules. A diagnosis of Nocardia keratitis was made and the patient was put on hourly topical 30% sulphacetamide eye drops and fortified gentamicin eye drops (14 mg/ml). 4 days later, the patient presented with increased pain and increased size of corneal ulceration. In addition, he developed a scleral abscess at the 6 o' clock position, 1 mm away from the limbus [Figure - 1]. The size of the scleral abscess was around 3 x 1.5 mm. The hypopyon increased to 2.5 mm. The culture plate showed cerebriform, yellow to deep orange colonies. The organism was identified as Nocardia asteroides based on the results of casein hydrolysis and Gelatin growth tests. The organism was sensitive to chloramphenicol, ciprofloxacin and norfloxacin, and was resistant to cotrimoxazole, gentamicin, and cefazoline. All antibiotics were stopped and the patient was started on 0.02% PHMB drops hourly during waking hours and 1% atropine twice a day. With this treatment, the patient improved and 10 days later, the scleral abscess resolved completely [Figure - 2]. The corneal infiltration also started to heal with healing edges. The infiltration completely healed by 3 weeks after the onset of treatment with PHMB 0.02%.


  Discussion Top


Nocardia keratitis is rare, with very few cases reported in the literature. Nearly all the reported cases were associated with trauma with organic material. The recommended drug of choice is a sulfonamide given via a combination of systemic and topical routes.[1] Other successful therapies include topical 10% ampicillin sodium, 0.3% norfloxacin and 0.3% ciprofloxacin.[2] In our case, the organism was resistant to gentamicin and cefazoline and sensitive to chloramphenicol, ciprofloxacin, and norfloxacin. Our previous experience with Nocardial keratitis had revealed varying drug sensitivities in concordance with previous reported studies.[3] Hence we decided to use 0.02% PHMB drops directly based on a previous case study report.[4]However, this reported case had only keratitis and no associated scleritis. Basti et al[5] have reported successful treatment of traumatic nocardia necrotising scleritis using cefazolin.

PHMB is a commercial environmental biocide commonly used as a swimming pool disinfectant. It has a broad spectrum of activity against both gram-positive and gram-negative bacteria and its antimicrobial activity increases with polymer length. It has been evaluated and confirmed as the treatment of choice for Acanthamoeba keratitis.[6]

The scleritis and keratitis in our case responded dramatically to 0.02% topical PHMB therapy alone. No systemic therapy was required. The scleritis responded first followed by the keratitis. PHMB may be a useful agent for Nocardial keratitis associated with scleritis also.

 
  References Top

1.
Hirst LW, Merz WG, Green WR. Nocardia asteroid corneal ulcer [letter]. Am J Ophthalmol 1982;94:123-34.  Back to cited text no. 1
[PUBMED]    
2.
Srinivasan M, Sundar K. Nocardial endophthalmitis [letter]. Arch Ophthalmology 1994;112:871-72.  Back to cited text no. 2
[PUBMED]    
3.
Bullock JD, Endogeneous Ocular Nocardiosis: a clinical and experimental study. Trans Am Ophthalmol Soc 1983;81:451-531.  Back to cited text no. 3
    
4.
Lin CJ, Ward TP, Belyea DA, Me Evoy P, Kramer KK. Treatment of Nocardia asteroides keratitis with polyhexamethylene biguanide. Ophthalmology 1997;104:1306-11.  Back to cited text no. 4
    
5.
Basti S, Gopinathan U, Gupta S. Nocardial necrotizing scleritis after trauma: successful outcome using cefazolin. Cornea 1994;13:274-76.  Back to cited text no. 5
[PUBMED]    
6.
Larkin DFP, Kilvington S, Dart JKG. Treatment of Acanthamoeba keratitis with polyhexamethylene biguanide. Ophthalmology 1992;99:185-91.  Back to cited text no. 6
    


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