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   Table of Contents      
Year : 2016  |  Volume : 64  |  Issue : 9  |  Page : 674-676

Infectious Pseudomonas and Bipolaris scleritis following history of pterygium surgery

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA

Date of Submission01-Jun-2015
Date of Acceptance09-Aug-2016
Date of Web Publication17-Nov-2016

Correspondence Address:
Dr. Leejee H Suh
Department of Cornea and External Diseases, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.194330

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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.

Keywords: Bipolaris, infectious scleritis, Pseudomonas, treatment

How to cite this article:
Abbey AM, Shah NV, Forster RK, Suh LH. Infectious Pseudomonas and Bipolaris scleritis following history of pterygium surgery. Indian J Ophthalmol 2016;64:674-6

How to cite this URL:
Abbey AM, Shah NV, Forster RK, Suh LH. Infectious Pseudomonas and Bipolaris scleritis following history of pterygium surgery. Indian J Ophthalmol [serial online] 2016 [cited 2020 Apr 6];64:674-6. Available from: http://www.ijo.in/text.asp?2016/64/9/674/194330

We present the first report of infectious scleritis secondary to Bipolaris fungus species without corneal infiltration. Bipolaris is a pigmented dematiaceous fungus which has been reported to induce mycotic keratitis, subcutaneous phaeohyphomycosis, sinusitis, peritonitis, and cerebral and disseminated infections.[1] The three most commonly reported species of Bipolaris are Bipolaris spicifera, Bipolaris hawaiiensis, and Bipolaris australiensis.[2] Structurally, these filamentous, septated hyphae molds contain asci that can have up to eight flagelliform or filiform ascospores. The multicellular, possibly pigmented fusoid to cylindrical-shaped conidia are produced through conidiophore wall pores and display a sympodial geniculate or zig-zag growth pattern.[3] The pigmented (dematiaceous) form displays a dark brown melanin-like color within the cell wall, which can be a useful clinical marker for infection.[4] However, as in our case, only 27.2% of eyes with dematiaceous fungal infection actually demonstrate such macroscopic pigmentation, which can provide a challenge for diagnosis. This is likely due to higher levels of inflammation that mask the pigmentation.[4]

  Case Report Top

A healthy 60-year-old male with a 30 pack-year smoking history presented with 2 months of right eye pain, headache, and photophobia. His ocular history was significant for pterygium excision with mitomycin C in the right eye 5 years ago as well infiltrative infectious scleritis secondary to Enterobacter cloacae and Curvularia fungus species 2 years ago. His first episode of the right eye infectious scleritis presented as scleral thinning 3 mm nasal to the limbus with overlying infiltrates that resolved with topical moxifloxacin and natamycin over the course of 3 months. However, a residual calcified plaque remained in the area of scleral thinning.

Two years later, the patient returned complaining of several weeks of worsening pain and photophobia in the right eye. On examination, his best-corrected visual acuity was 20/25 in the right eye and 20/20 in the left eye. Slit-lamp examination of the left eye was normal. Examination of the right eye revealed soft, yellow-white purulent material overlying the existing calcified plaque with extensive scleral thinning [Figure 1]. Fundus examination in both eyes was normal.
Figure 1: Slit-lamp photograph of the right eye 2 years after initial presentation, now with an elevated mass of purulence overlying the area of scleral thinning

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A limbal peritomy was performed to define the areas of scleral thinning, and the purulent material was noted to be adherent to the calcific plaque. The plaque and purulent material were excised with gentle traction and sent for culture and histopathology. To avoid scleral perforation, a Tutoplast ® scleral graft was sutured over the scleral defect and covered with a conjunctival flap. Initially, the patient was treated with hourly topical moxifloxacin, fortified tobramycin, and natamycin.

Von Kossa stains of the scleral plaque showed marked calcification. Gomori methenamine silver stains of the purulent material eventually revealed a marked amount of branching fungal hyphae (indicated by arrow) with cultures growing Pseudomonas aeruginosa and Bipolaris fungus [Figure 2].
Figure 2: Gomori methenamine silver stain of purulent area demonstrating numerous branching hyphae (arrow) indicative of fungus

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Nine days after the procedure, the patient developed moderate discomfort in the right eye. Examination revealed a retracted conjunctival flap with further purulent material overlying the scleral patch graft. A decision was made to inject subconjunctival voriconazole, and QID dosing of topical cyclosporine 2% plus oral ketoconazole (400 mg daily) was added to his treatment plan. After 10 weeks of treatment, the patient's symptoms had resolved, and vision returned to baseline [Figure 3]. Once clinical evidence of infection resolved, medications were discontinued.
Figure 3: Slit-lamp photograph of the right eye on postoperative month 3 with epithelialization of the scleral patch graft and resolved infection

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  Discussion Top

In our patient, aggressive medical and surgical management resulted in complete resolution of the infection. Surgical intervention was elected due to the chronicity and recurrence of the lesion and due to the possibility of impending scleral perforation.In vitro strains of dematiaceous fungi have shown to respond well to antifungals such as natamycin and amphotericin B.[1] Hence, a suggested clinical treatment modality includes topical natamycin 5% supplemented with oral ketoconazole.[4] Keratitis has been shown to resolve in over 70% of cases with dematiaceous fungi,[5] but poor penetration of antimicrobials through the collagen-bound scleral layer poses a challenge for effective treatment.[6] The persistence of organisms such as Pseudomonas species and fungal hyphae in the sclera despite aggressive medical therapy has been reported.[7] For such cases of infectious keratoscleritis that are refractive to medical treatment such as this particular case, the best option may be to include surgical management such as excision with lamellar corneoscleral graft and/or cryotherapy.[8]

Infectious scleritis typically presents as an extension of keratitis resulting from ocular injury, often from trauma, foreign bodies, radiation, or surgery. Infectious scleritis following pterygium removal has been reported, and is often related to postoperative beta irradiation and/or intraoperative antimetabolites.[9] The events resulting in an infection involve direct pathogenic invasion of the sclera that triggers an immune-mediated vasculitis and necrosis at the site of pterygium excision.[9] Hence, if a presumed inflammatory scleritis does not respond as expected to steroid treatment, an infectious etiology should be considered. Such cases can be diagnosed through smear/culture, scleral biopsy, or anterior chamber aspirate. Poor prognosis in infectious scleritis includes corneal involvement, inappropriate antimicrobial therapy, and presence of fungal infection. Thus, mycotic scleritis should always be considered in the differential diagnosis, and prompt diagnoses and treatment are critical to salvage vision.[1] To our knowledge, this is the first report of infectious scleritis without corneal involvement caused by the Bipolaris species.[10]

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Conflicts of interest

There are no conflicts of interest.

  References Top

Forster RK, Rebell G, Wilson LA. Dematiaceous fungal keratitis. Clinical isolates and management. Br J Ophthalmol 1975;59:372-6.  Back to cited text no. 1
Anandi V, Suryawanshi NB, Koshi G, Padhye AA, Ajello L. Corneal ulcer caused by Bipolaris hawaiiensis. J Med Vet Mycol 1988;26:301-6.  Back to cited text no. 2
Collier LA, Sussman B. Microbiology and Microbial Infections: Topley and Wilson's Microbiology and Microbial Infections. 9th ed. London, Sydney, Auckland, New York: Topley and Wilson; 1998.  Back to cited text no. 3
Garg P, Vemuganti GK, Chatarjee S, Gopinathan U, Rao GN. Pigmented plaque presentation of dematiaceous fungal keratitis: A clinicopathologic correlation. Cornea 2004;23:571-6.  Back to cited text no. 4
Alfonso E, Kenyon KR, Ormerod LD, Stevens R, Wagoner MD, Albert DM. Pseudomonas corneoscleritis. Am J Ophthalmol 1987;103:90-8.  Back to cited text no. 5
Moriarty AP, Crawford GJ, McAllister IL, Constable IJ. Fungal corneoscleritis complicating beta-irradiation-induced scleral necrosis following pterygium excision. Eye (Lond) 1993;7(Pt 4):525-8.  Back to cited text no. 6
Reynolds MG, Alfonso E. Treatment of infectious scleritis and keratoscleritis. Am J Ophthalmol 1991;112:543-7.  Back to cited text no. 7
Hsiao CH, Chen JJ, Huang SC, Ma HK, Chen PY, Tsai RJ. Intrascleral dissemination of infectious scleritis following pterygium excision. Br J Ophthalmol 1998;82:29-34.  Back to cited text no. 8
Saha R, Das S. Bipolaris keratomycosis. Mycoses 2005;48:453-5.  Back to cited text no. 9
Liesegang TJ, Forster RK. Spectrum of microbial keratitis in South Florida. Am J Ophthalmol 1980;90:38-47.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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