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PHOTO ESSAY
Year : 2020  |  Volume : 68  |  Issue : 10  |  Page : 2227-2228

Kill with cold


Department of Vitreretina and Ocular Oncology, Sankara Eye Hospital, Bengaluru, Karnataka, India

Date of Submission15-Jan-2020
Date of Acceptance06-May-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
Dr. Maithili Mishra
Sankara Eye Hospital, Kundalahalli, Varthur Road, Bengaluru- 560 037, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_79_20

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  Abstract 


Keywords: Fungal granuloma , Endophthalmitis, triple freeze thaw


How to cite this article:
Mishra M, Ramanjulu R, Shanmugam M, Mishra D. Kill with cold. Indian J Ophthalmol 2020;68:2227-8

How to cite this URL:
Mishra M, Ramanjulu R, Shanmugam M, Mishra D. Kill with cold. Indian J Ophthalmol [serial online] 2020 [cited 2020 Oct 30];68:2227-8. Available from: https://www.ijo.in/text.asp?2020/68/10/2227/295761



We describe 2 cases of fungal ciliary body granuloma, and its effective management.

Case 1: A 13-year-old boy, post corneal tear repair presented with endophthalmitis with superior ciliary body granuloma [Figure 1]. Though pars plana vitrectomy (PPV) with amphotericin-B cleared the vitreous, the granuloma persisted. Systemic fluconazole 50 mg BD (3 weeks) had no effect. Microbiologically it was dematiaceous fungi.[1] Triple freeze thaw cryotherapy was applied under direct visualization excluding iris or the retinal surface. Patient showed a good response with complete regression in 3 days [Figure 2]. He underwent secondary intraocular lens (IOL) implantation with best-corrected visual acuity (BCVA) of 20/80 after 8 weeks.
Figure 1: Black arrows show yellowish granulomas hanging from the ciliary body superiorly behind the iris with vitreous exudates and green arrow shows site of corneal tear repair

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Figure 2: Postop 3 months, granuloma regressed completely

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Case 2: A 36-year-old lady of 6 weeks postpartum, presented with the features suggestive of endogenous endophthalmitis. She underwent PPV and was found to have retinal detachments (RD) with subretinal exudates and a large granuloma arising from the ciliary body with posterior extension [Figure 3]. Laser around necrotic areas with silicon oil infusion was done to reattach the retina. Though the vitreous aspirate had a negative yield, we continued systemic antifungal (voriconazole 200 mg BD × 2 weeks) in view of clinical profile.[2],[3] Since her ocular condition deteriorated with enlarging granuloma, triple freeze thaw cryotherapy was applied directly over the granuloma. The lesion regressed completely. Visual rehabilitation with scleral fixated intraocular lens (SFIOL) was done 3 months later with a BCVA of 20/200.
Figure 3: Fundus image after clearing of vitreous exudates at the first surgery shows an oil filled eye and outlined area depicts location of suspected granuloma to which cryotherapy was applied later

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  Discussion Top


The fungal infection of the eye, particularly of the posterior segment is difficult to treat. They usually follow a relapsing course with recurring infiltration and exudates, ultimately leading to phthisis bulbi. Cryotherapy has been previously mentioned in literature as salvage therapy for resistant fungal infiltrates of anterior segment and transplanted cornea.[4],[5],[6],[7],[8] We similarly applied cryo probe for 8 to 10 s [Figure 4] and [Figure 5] and allowed it to thaw for 1 whole min before refreezing. In conclusion, fungal granuloma of the ciliary body can be safely and effectively treated with triple freeze thawing.
Figure 4: (a) Fundus image of the oil filled right eye after cryotherapy was applied to suspected granuloma area shown in Figure 3. (b) Area of scarring after triple freeze thaw cryotherapy and complete resolution of the granuloma

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Figure 5: Demonstrates technique of triple freeze thaw cryotherapy for intraocular fungal granuloma. Cryoprobe is applied over the area of ciliary body granuloma to freeze for 8–10 s and is allowed to thaw for 1 whole min before refreezing, cycle is done totally for three times

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fox AR, Houser KH, Morris WR, Walton RC. Dematiaceous fungal endophthalmitis: Report of a case and review of the literature.J Ophthal Inflamm Infect2016;6:43.  Back to cited text no. 1
    
2.
Tsai CC, Chen SJ, Chung YM, Yu KW, Hsu WM. Postpartum endogenous Candida endophthalmitis. J Formos Med Assoc 2002;101:432-6.  Back to cited text no. 2
    
3.
Lingappan A, Wykoff CC, Albini TA, Miller D, Pathengay A, Davis JL, et al. Endogenous fungal endophthalmitis: Causative organisms, management strategies, and visual acuity outcomes. Am J Ophthalmol 2012;153:162-6.  Back to cited text no. 3
    
4.
Doshi S, Pathengay A, Hegde S, Panchal B. Can cryotherapy be used as an adjunct in select cases of recalcitrant endophthalmitis?-A case report. Indian J Ophthalmol 2019;67:1894-6.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Das T. Commentary: Can cryotherapy be used as an adjunct in select cases of recalcitrant endophthalmitis? Indian J Ophthalmol 2019;67:1897.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Agarwal S, Iyer G, Srinivasan B, Benurwar S, Agarwal M, Narayanan N, et al. Clinical profile, risk factors and outcome of medical, surgical and adjunct interventions in patients with Pythiuminsidiosum keratitis. Br J Ophthalmol 2019;103:296-300.  Back to cited text no. 6
    
7.
Rodriguez-Ares MT, De Rojas Silva MV, Pereiro M, Fente Sampayo B, Gallegos Chamas G, S-Salorio M. Aspergillus fumigatus scleritis. Acta Ophthalmol Scand 1995;73:467-9.  Back to cited text no. 7
    
8.
Ting DS, Bignardi G, Koerner R, Irion LD, Johnson E, Morgan SJ, et al. Polymicrobial keratitis with cryptococcus curvatus, candida parapsilosis, and stenotrophomonas maltophilia after penetrating keratoplasty: A rare case report with literature review. Eye Contact Lens 2019;45:e5-10.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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