|Year : 1975 | Volume
| Issue : 2 | Page : 29-30
An unusual case of scleral involvement by pseudomonas pyocyaneous
Shashi Kapoor, AK Gupta, Manorma Sood
Department of Ophthalmology, Maulana Azad Medical College, New Delhi-1, India
Department of Ophthalmology, Maulana Azad Medical College, New Delhi-1
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kapoor S, Gupta A K, Sood M. An unusual case of scleral involvement by pseudomonas pyocyaneous. Indian J Ophthalmol 1975;23:29-30
Scleritis is known to occur as an acute pyogenic, non pyogenic and necrotizing inflammation in rnycotic, viral, chronic infective conditions (tuberculosis, syphilis and leprosy), erythema nodosum, rheumatoid arthritis and metabolic conditions (gout and porphyria). Acute pyogenic involvment of the sclera is known to occur rarely in bacterial infections (staph. aureus, staph. albus) and mycotic infections (aspergillosis, sporotrichosis).
Pseudomonas pyocyaneous infection of the sclera producing its softening and necrosis is not well documented. Jain and Gupta  reported one such case. In this article another case of scleral necrosis by Pseudomonas pyocvaneous is being reported because of its rare occurrence.
| Case Report|| |
Patient H.S. aged 26 years reported with sudden development of acute pain, watering and total loss of vision in left eye for 7 days. There was no history of any predisposing factors as trauma or fever. On examination left eye showed marked oedema of the lids.
The conjunctiva was markedly hyperaemic and chemosed. No part of the sclera was visible and there was no evidence of any undue thickening or nodule formation. The whole of the cornea was necrosed and had greenish yellow discharge. Nothing was visible behind the cornea. The tension was high and the projection of rays defective in two quadrants.
Conjunctival culture showed Pseudomonas pyocyaneous sensitive to garamycin. Systemic examination did not reveal any abnormality.
The patient was put on genticyn drops, oral diamox and systemic antibiotics for 5 days. Since there was no response to medication, therapeutic keratoplasty was undertaken under mannitol drip. Eleven millimeter trephine was used to mark the donor cornea which was cut through its full thickness in about one half of the circumference. Trephine of the same diameter was used on recepient cornea. A good resistance was felt while cutting the recepient cornea at limbus except on the nasal side which was found to be very soft and necrosed. The sclera on this side was friable and was giving way on holding with fine forceps. The softening extended for 2 mm from the limbus on the nasal side. This created a vertical defect of 11 mm and horizontal of 13 mm.
Since the donor cornea was already cut through full thickness in half of its circumference the donor tissue was dissected for 2 more mm on the scleral side. Thus replacing tissue was 11 mm vertically and 13 mm horizontally. Continuous sutures were used for retention of the graft. On the nasal side the sclera was still found to be friable and another 3 mm: had to be removed. Suturing on the nasal side was completed taking big bites of the conjunctiva. Air was injected and subconjunctivial injection of genticyn was given.
In the post operative period, he was put on diamox tanderil and achromycin. In retrospective, patient was investigated and did rot show any evidence of tuberculosis and rheumatoid arthritis.
Twelve weeks after the operation, the graft had taken up completely. It had gone opaque in the lower part. The pupillary area was clear. Intraocular pressure was normal and projection of rays accurate. The patient could count fingers from a distance of 5 meters.
| Discussion|| |
Fulminating involvement of the cornea by Pseudomonas pyocyaneous is well known but the scleral involvement is not well documented. It forms scleral abscess after enzymatic digestion which produces softening and necrosis. The scleral involvement can be because of its continuity with cornea. The rare involvement of sclera in pyogenic infections could be due to its tough structure, avascularity and good coverage by conjunctiva.
The replacement of bigger recepient gap by a smaller donor tissue, as in this case, indicates that the cornea can be sutured quite safely to any of the recepient tissues when there is paucity of donor tissue. Though a good part of drainage channels is removed on corneascleral grafting, it may not produce the problem of secondary glaucoma as anticipated.
| Summary|| |
An unusual case of scleral softening due to Pseudomonas pyocyaneous infection is reported. A vertical gap of 11 mm and horizontal of 16 mm was replaced by corneoscleral graft measuring 11 mm vertically and 13 mm horizontally successfully saving the structure and some function of the eye.
| References|| |
Jain, I.S., Gupta S.D. Oriental Arch. Ophthal 1969 7,325.