Correspondence that developed in response to the posterior segment inflammation. We believed that the radial folds had caused persisting tangential traction on the macula that eventually led to the formation of macular hole. Macular hole has also been described as a rare sequela in other ocular inflammatory diseases such as cat scratch disease, presumed ocular histoplasmosis, and fungal endophthalmitis.5–7 To our knowledge, this is the first reported case of macular hole after ocular rickettsioses. This case also highlights the need for ongoing monitoring in ocular rickettsioses until complete clinical resolution is achieved, because sequela may sometimes develop later in the course of follow-up. Soo Khai Ng, Sumu Simon, Jagjit S. Gilhotra South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, South Australia, Australia. Correspondence to: Soo Ng, MBBS: [email protected] REFERENCES
Fig. 1 — A, High-resolution optical coherence tomography (OCT) of right macula demonstrating full-thickness macular hole. B, OCT at 5 months after surgical repair showing closed macular hole with residual subfoveal cyst.
Rickettsia infections can be broadly classified into 3 main groups: the spotted fever, the typhus, and the scrub typhus.1,2 Within the spotted fever group, Rickettsia conorii is the most widespread and is the causative agent for Mediterranean spotted fever in humans, a disease endemic in Mediterranean countries and certain parts of India.2 Our patient had Mediterranean spotted fever caused by Rickettsia conorii with bilateral posterior segments involvement. The bilateral subtle optic disc edema and mild vitritis showed prompt resolution with systemic therapy. The radial macular folds probably represent inflammatory contraction of premacular cortical vitreous
Case of acquired night blindness in a hemodialysis patient Vitamin A is coupled to retinol binding protein (RBP) in the liver and is secreted into the bloodstream where it combines with prealbumin in the plasma. After supplying vitamin A to the targeted cells, the RBP is absorbed and disseminated in the kidney. Therefore, the level of plasma RBP is reduced in patients with liver disturbances and, conversely, is elevated in a patient with renal dysfunction.1 In patients undergoing dialysis, the vitamin
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1. Khairallah M, Kahloun R, Ben Yahia S, Jelliti B, Messaoud R. New infectious etiologies for posterior uveitis. Ophthalmic Res. 2013;49: 66-72. 2. Pinna A. Ocular manifestations of rickettsiosis: 1. Mediterranean spotted fever: Laboratory analysis and case reports. Int J Med Sci. 2009;6:126-7. 3. Khairallah M, Ladjimi A, Chakroun M, et al. Posterior segment manifestations of Rickettsia conorii infection. Ophthalmology. 2004; 111:529-34. 4. Agahan AL, Torres J, Fuentes-Páez G, et al. Intraocular inflammation as the main manifestation of Rickettsia conorii infection. Clin Ophthalmol. 2011;5:1401-7. 5. Albini TA, Lakhanpal RR, Foroozan R, Holz ER. Macular hole in cat scratch disease. Am J Ophthalmol. 2005;140:149-51. 6. Baskin MA, Jampol LM, Huamonte FU, et al. Macular lesions in blacks with the presumed ocular histoplasmosis syndrome. Am J Ophthalmol. 1980;89:77-83. 7. Kusaka S, Hayashi N, Ohji M, et al. Macular hole secondary to fungal endophthalmitis. Arch Ophthalmol. 2003;121:732-3. Can J Ophthalmol 2013;48:e147–e148 0008-4182/13/$-see front matter Crown Copyright & 2013 Published by Elsevier Inc on behalf of the Canadian Ophthalmological Society. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2013.08.009
A concentration in the serum and the RBP in the plasma are usually increased.2 We report a dialysis patient who experienced development of night blindness in spite of normal vitamin A levels in the serum. A 57-year-old Japanese male who reported difficulties in dim light for 2 months was referred to our clinic. He had been diagnosed with the nephrotic syndrome and had undergone hemodialysis since he was 50 years old. An intracranial hemorrhage was diagnosed 4 months earlier. Our examination showed that his best corrected visual acuity was 20/20 OU, and his intraocular pressure was 10
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
Correspondence mm Hg OU. A slit-lamp examination showed no abnormal finding in both eyes, and ophthalmoscopy showed sparse white flecks in the midperipheral retina of both eyes (Fig. 1A). Fundus autofluorescence of the retina demonstrated scattered hypofluorescent and hyperfluorescent lesions corresponding to the white flecks in both eyes (Fig. 1C). Horizontal spectral domain optical coherence tomography (SD-OCT) showed a disrupted cone outer segment tips line in both foveae (Fig. 1B). A vertical SD-OCT scan in the midperipheral retina revealed shadows that extended from the RPE into the outer nuclear layer (Fig. 1D). Static perimetric examinations showed full visual fields with normal retinal sensitivity in both eyes. Panel D-15 test indicated that the patient had a trichromatic defect. The critical flicker fusion frequency was 40 Hz OU. The Schirmer test was 6 mm OD and 1 mm OS. The b-wave of the rod electroretinograms (ERGs) was unrecordable (Primus Electrophysiology system; TOMEY, Nagoya, Japan), and the bright-flash mixed rod-cone ERG consisted of a markedly reduced b-wave and a small a-wave resulting in a reduced negative-type ERG (Fig. 2). The amplitudes of the cone b-wave and 30-Hz flicker ERGs were almost normal (Fig. 2). After 3 hours of dark adaptation, the single bright-flash ERGs did not improve. Laboratory tests revealed normal total and direct bilirubin levels, increased aspartate aminotransferase level, and normal γ-glutamyl transferase level. The levels of urea nitrogen and creatinine were high. The serum level of vitamin A was within the normal range. The serum level of RBP was high (Table 1). Initially, we advised the patient to improve his diet with the proper proportions of the 3 main food groups and to eat low-energy foods such as vegetables. However, even
though his serum vitamin A level was within the normal range, oral retinol palmitate (30,000 IU/day) was initiated. Thereafter, his symptoms improved, and there was an improvement in the amplitude of the single bright-flash ERGs (Fig. 2). The serum vitamin A level and RBP level were both increased beyond the normal range (Table 1). In addition, the colour vision was restored to normal. However, the sparse white flecks in the fundus remained. The ocular complications associated with hemodialysis include calcium deposits in the conjunctiva and cornea, an increase in the intraocular pressure, a progression of cataracts, and bullous retinal detachments.3 However, an acquired night blindness associated with hemodialysis has not been reported. Although the serum level of RBP is often estimated to be higher in dialysis patients, most of it is present in the form of apo-RBP, which does not bind to retinol.1 The estimated higher level of serum RBP should result in higher levels of serum vitamin A.4 However, the increase in serum vitamin A might be less than the increase in RBP in dialysis patients.5 In addition, the serum vitamin A levels in patients undergoing dialysis is more likely to accumulate because the metabolism of vitamin A to retinoic acid is impaired in the kidney.6 In contrast, it has been suggested that the level of vitamin A should be low in the liver, fat tissues, and other organs except the epithelium of the skin.2,5 Therefore, we suggest that that the level of vitamin A might be low in the retinal tissues of our patient in spite of the normal serum level of vitamin A. This would finally lead to the development of night blindness. In summary, we report a patient undergoing dialysis who acquired night blindness in spite of normal serum levels of vitamin A. The administration of vitamin A
Fig. 1 — A, Fundus photograph of the left eye of a patient undergoing dialysis. Note sparse white flecks in the midperipheral retina. B and D, The OCT images around the fovea (B) and the midperipheral retina (D). C, Fundus autofluorescence of the retina of his left eye. CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
e149
Correspondence 60 days after administration
Initial Visit
Normal
140 days after administration
Rt.
Rod
Lt.
200µV 40ms
Mixed Rod cone
Rt. Lt.
200µV
30ms Rt.
OP Lt.
100µV 20ms
Rt.
30Hz Flicker
100µV
Lt.
30ms Rt.
Cone 100µV
Lt.
40ms
Fig. 2 — Full-field electroretinograms (ERGs) recorded at the initial visit (second column) from a patient undergoing hemodialysis and after therapy with oral retinol palmitate (third and fourth columns). At the initial visit, the b-wave of the rod ERGs was unrecordable, and the bright-flash mixed rod-cone ERG consisted of a markedly reduced b-wave and a small a-wave resulting in a reduced negative-type ERG (second column). The amplitudes of the cone b-wave and 30-Hz flicker ERGs were almost normal (second column). Note the increase of the b-wave and b-wave amplitude under scotopic conditions after the treatment (third and fourth columns).
Table 1—Change of laboratory data After Oral Administration of Vitamin A (month) Data
Normal Value
Creatinine, mg/mL Urea nitrogen, mg/dL Vitamin A, IU/dL Retinol-binding protein, mg/dL Iron, mg/dL Ferritin, ng/mL Copper, mg/dL Zinc, mg/dL Folic acid, ng/mL Vitamin B12, pg/mL 1,25-dihydroxyvitamin D, pg/mL Alanine aminotransferase, IU/L Aspartate aminotransferase, IU/L γ-Glutamyltranspeptidase, IU/L
0.60–1.20 8.0–20.0 97–316 2.4–7.0 50–180 21.8–274.7 68–128 65–110 ≥3.1 180–914 20.0–60.0 7–40 7–35 o70
Initial Visit 11.88 50.3 288 12.5 48 65.5 81 114 2.8 461 12.5 7 5 13
0
1
5
8
11.14 28.7 227 12 110 406.7 104 79 2.8 609 13.2 — — —
11.67 33.9 510 15.7 131 441.6 95 85 3.2 557 22.3 — — —
10.58 30.2 493 15.7 58 295.3 96 92 4 472 10.6 — — —
9.77 20.8 414 14.1 66 226.9 91 89 2 324 12.4 — — —
Italics indicate the values exceeding the upper limit of the normal range.
improved his symptoms and ocular findings including the ERGs. Takashi Nishida, * Akira Sawada, * Kiyofumi Mochizuki, * Yoshiaki Niwa, † Kazuyoshi Hayakawa ‡
University Graduate School of Medicine; †Gifu Prefectural General Medical Center; ‡JA Gifu Koseiren Gihoku General Hospital, Gifu, Japan
*Gifu
Correspondence to: Akira Sawada, MD: [email protected]
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REFERENCES 1. Smith FR, Goodman DS. The effects of diseases of the liver, thyroid, and kidneys on the transport of vitamin A in human plasma. J Clin Invest. 1971;50:2426-36. 2. Vahlquist A, Berne B, Danielson BG, Grefberg N, Berne C. Vitamin A lossesduring continuous ambulatory peritoneal dialysis. Nephron. 1985;41:179-83. 3. Pahor D. Retinal light sensitivity in haemodialysis patients. Eye. 2003;17:177-82. 4. Stewart WK, Fleming LW. Plasma retinol and retinol binding protein concentrations in patients on maintenance haemodialysis with and without vitamin A supplements. Nephron. 1982;30:15-21.
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
Correspondence 5. Stein G, Schöne S, Geinitz D, et al. No tissue level abnormality of vitamin A concentration despite elevated serum vitamin A of uremic patients. Clin Nephrol. 1986;25:87-93. 6. Yatzidis H, Digenis P, Fountas P. Hypervitaminosis A accompanying advanced chronic renal failure. Br Med J. 1975;3:352-3.
Clinicopathologic case reports of Alternaria and Fusarium keratitis in Canada Fungal keratitis is prevalent in tropical environments, making up 35% of all keratitis cases in Florida.1 However, few cases have been reported in more temperate regions such as Canada.1–3 In this article, we present 2 Canadian farmers who experienced keratitis involving a dematiaceous fungus, Alternaria alternata, and a Fusarium species, respectively.
Can J Ophthalmol 2013;48:e148–e151 0008-4182/13/$-see front matter & 2013 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2013.06.006
CASE 1 In a farming accident, a 49-year-old male sustained a severe alkali injury to his left eye (OS), reducing his visual acuity to 20/120 (Fig. 1A). He developed a hypopyon, which slowly improved on topical 1% prednisolone acetate and oral prednisone (50 mg daily) while continuing with prophylactic topical moxifloxacin and tobramycin. His corneal opacification progressed to an inferior descemetocele. Four months after presentation, he received a Boston keratoprosthesis (k-pro).
Fig. 1 — A, Corneal ulceration after alkaline chemical burns to the left eye. B, One month after k-pro implantation with the infectious process infiltrating into the graft material. C, The corneal specimen is severely necrotic with irregular thinning of the inflamed stroma (hematoxylin and eosin, 25 original magnification). D, The Grocott–Gomori methenamine silver stain (GMS) shows numerous filamentous fungi at all levels predominantly anteriorly in the necrotic central stroma (200 original magnification). E, Higher magnification of septated fungi (GMS, 640 original magnification). F, Tease mount of a 72-hour culture growth that has been stained with lactophenol cotton blue, showing large, brown pigmented, muriform macroconidia occurring in short chains that is characteristic of Alternaria species (640 original magnification). CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
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Fig. 1 — A, High-resolution optical coherence tomography (OCT) of right macula demonstrating full-thickness macular hole. B, OCT at 5 months after surgical repair showing closed macular hole with residual subfoveal cyst.
Rickettsia infections can be broadly classified into 3 main groups: the spotted fever, the typhus, and the scrub typhus.1,2 Within the spotted fever group, Rickettsia conorii is the most widespread and is the causative agent for Mediterranean spotted fever in humans, a disease endemic in Mediterranean countries and certain parts of India.2 Our patient had Mediterranean spotted fever caused by Rickettsia conorii with bilateral posterior segments involvement. The bilateral subtle optic disc edema and mild vitritis showed prompt resolution with systemic therapy. The radial macular folds probably represent inflammatory contraction of premacular cortical vitreous
Case of acquired night blindness in a hemodialysis patient Vitamin A is coupled to retinol binding protein (RBP) in the liver and is secreted into the bloodstream where it combines with prealbumin in the plasma. After supplying vitamin A to the targeted cells, the RBP is absorbed and disseminated in the kidney. Therefore, the level of plasma RBP is reduced in patients with liver disturbances and, conversely, is elevated in a patient with renal dysfunction.1 In patients undergoing dialysis, the vitamin
e148
1. Khairallah M, Kahloun R, Ben Yahia S, Jelliti B, Messaoud R. New infectious etiologies for posterior uveitis. Ophthalmic Res. 2013;49: 66-72. 2. Pinna A. Ocular manifestations of rickettsiosis: 1. Mediterranean spotted fever: Laboratory analysis and case reports. Int J Med Sci. 2009;6:126-7. 3. Khairallah M, Ladjimi A, Chakroun M, et al. Posterior segment manifestations of Rickettsia conorii infection. Ophthalmology. 2004; 111:529-34. 4. Agahan AL, Torres J, Fuentes-Páez G, et al. Intraocular inflammation as the main manifestation of Rickettsia conorii infection. Clin Ophthalmol. 2011;5:1401-7. 5. Albini TA, Lakhanpal RR, Foroozan R, Holz ER. Macular hole in cat scratch disease. Am J Ophthalmol. 2005;140:149-51. 6. Baskin MA, Jampol LM, Huamonte FU, et al. Macular lesions in blacks with the presumed ocular histoplasmosis syndrome. Am J Ophthalmol. 1980;89:77-83. 7. Kusaka S, Hayashi N, Ohji M, et al. Macular hole secondary to fungal endophthalmitis. Arch Ophthalmol. 2003;121:732-3. Can J Ophthalmol 2013;48:e147–e148 0008-4182/13/$-see front matter Crown Copyright & 2013 Published by Elsevier Inc on behalf of the Canadian Ophthalmological Society. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2013.08.009
A concentration in the serum and the RBP in the plasma are usually increased.2 We report a dialysis patient who experienced development of night blindness in spite of normal vitamin A levels in the serum. A 57-year-old Japanese male who reported difficulties in dim light for 2 months was referred to our clinic. He had been diagnosed with the nephrotic syndrome and had undergone hemodialysis since he was 50 years old. An intracranial hemorrhage was diagnosed 4 months earlier. Our examination showed that his best corrected visual acuity was 20/20 OU, and his intraocular pressure was 10
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
Correspondence mm Hg OU. A slit-lamp examination showed no abnormal finding in both eyes, and ophthalmoscopy showed sparse white flecks in the midperipheral retina of both eyes (Fig. 1A). Fundus autofluorescence of the retina demonstrated scattered hypofluorescent and hyperfluorescent lesions corresponding to the white flecks in both eyes (Fig. 1C). Horizontal spectral domain optical coherence tomography (SD-OCT) showed a disrupted cone outer segment tips line in both foveae (Fig. 1B). A vertical SD-OCT scan in the midperipheral retina revealed shadows that extended from the RPE into the outer nuclear layer (Fig. 1D). Static perimetric examinations showed full visual fields with normal retinal sensitivity in both eyes. Panel D-15 test indicated that the patient had a trichromatic defect. The critical flicker fusion frequency was 40 Hz OU. The Schirmer test was 6 mm OD and 1 mm OS. The b-wave of the rod electroretinograms (ERGs) was unrecordable (Primus Electrophysiology system; TOMEY, Nagoya, Japan), and the bright-flash mixed rod-cone ERG consisted of a markedly reduced b-wave and a small a-wave resulting in a reduced negative-type ERG (Fig. 2). The amplitudes of the cone b-wave and 30-Hz flicker ERGs were almost normal (Fig. 2). After 3 hours of dark adaptation, the single bright-flash ERGs did not improve. Laboratory tests revealed normal total and direct bilirubin levels, increased aspartate aminotransferase level, and normal γ-glutamyl transferase level. The levels of urea nitrogen and creatinine were high. The serum level of vitamin A was within the normal range. The serum level of RBP was high (Table 1). Initially, we advised the patient to improve his diet with the proper proportions of the 3 main food groups and to eat low-energy foods such as vegetables. However, even
though his serum vitamin A level was within the normal range, oral retinol palmitate (30,000 IU/day) was initiated. Thereafter, his symptoms improved, and there was an improvement in the amplitude of the single bright-flash ERGs (Fig. 2). The serum vitamin A level and RBP level were both increased beyond the normal range (Table 1). In addition, the colour vision was restored to normal. However, the sparse white flecks in the fundus remained. The ocular complications associated with hemodialysis include calcium deposits in the conjunctiva and cornea, an increase in the intraocular pressure, a progression of cataracts, and bullous retinal detachments.3 However, an acquired night blindness associated with hemodialysis has not been reported. Although the serum level of RBP is often estimated to be higher in dialysis patients, most of it is present in the form of apo-RBP, which does not bind to retinol.1 The estimated higher level of serum RBP should result in higher levels of serum vitamin A.4 However, the increase in serum vitamin A might be less than the increase in RBP in dialysis patients.5 In addition, the serum vitamin A levels in patients undergoing dialysis is more likely to accumulate because the metabolism of vitamin A to retinoic acid is impaired in the kidney.6 In contrast, it has been suggested that the level of vitamin A should be low in the liver, fat tissues, and other organs except the epithelium of the skin.2,5 Therefore, we suggest that that the level of vitamin A might be low in the retinal tissues of our patient in spite of the normal serum level of vitamin A. This would finally lead to the development of night blindness. In summary, we report a patient undergoing dialysis who acquired night blindness in spite of normal serum levels of vitamin A. The administration of vitamin A
Fig. 1 — A, Fundus photograph of the left eye of a patient undergoing dialysis. Note sparse white flecks in the midperipheral retina. B and D, The OCT images around the fovea (B) and the midperipheral retina (D). C, Fundus autofluorescence of the retina of his left eye. CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
e149
Correspondence 60 days after administration
Initial Visit
Normal
140 days after administration
Rt.
Rod
Lt.
200µV 40ms
Mixed Rod cone
Rt. Lt.
200µV
30ms Rt.
OP Lt.
100µV 20ms
Rt.
30Hz Flicker
100µV
Lt.
30ms Rt.
Cone 100µV
Lt.
40ms
Fig. 2 — Full-field electroretinograms (ERGs) recorded at the initial visit (second column) from a patient undergoing hemodialysis and after therapy with oral retinol palmitate (third and fourth columns). At the initial visit, the b-wave of the rod ERGs was unrecordable, and the bright-flash mixed rod-cone ERG consisted of a markedly reduced b-wave and a small a-wave resulting in a reduced negative-type ERG (second column). The amplitudes of the cone b-wave and 30-Hz flicker ERGs were almost normal (second column). Note the increase of the b-wave and b-wave amplitude under scotopic conditions after the treatment (third and fourth columns).
Table 1—Change of laboratory data After Oral Administration of Vitamin A (month) Data
Normal Value
Creatinine, mg/mL Urea nitrogen, mg/dL Vitamin A, IU/dL Retinol-binding protein, mg/dL Iron, mg/dL Ferritin, ng/mL Copper, mg/dL Zinc, mg/dL Folic acid, ng/mL Vitamin B12, pg/mL 1,25-dihydroxyvitamin D, pg/mL Alanine aminotransferase, IU/L Aspartate aminotransferase, IU/L γ-Glutamyltranspeptidase, IU/L
0.60–1.20 8.0–20.0 97–316 2.4–7.0 50–180 21.8–274.7 68–128 65–110 ≥3.1 180–914 20.0–60.0 7–40 7–35 o70
Initial Visit 11.88 50.3 288 12.5 48 65.5 81 114 2.8 461 12.5 7 5 13
0
1
5
8
11.14 28.7 227 12 110 406.7 104 79 2.8 609 13.2 — — —
11.67 33.9 510 15.7 131 441.6 95 85 3.2 557 22.3 — — —
10.58 30.2 493 15.7 58 295.3 96 92 4 472 10.6 — — —
9.77 20.8 414 14.1 66 226.9 91 89 2 324 12.4 — — —
Italics indicate the values exceeding the upper limit of the normal range.
improved his symptoms and ocular findings including the ERGs. Takashi Nishida, * Akira Sawada, * Kiyofumi Mochizuki, * Yoshiaki Niwa, † Kazuyoshi Hayakawa ‡
University Graduate School of Medicine; †Gifu Prefectural General Medical Center; ‡JA Gifu Koseiren Gihoku General Hospital, Gifu, Japan
*Gifu
Correspondence to: Akira Sawada, MD: [email protected]
e150
REFERENCES 1. Smith FR, Goodman DS. The effects of diseases of the liver, thyroid, and kidneys on the transport of vitamin A in human plasma. J Clin Invest. 1971;50:2426-36. 2. Vahlquist A, Berne B, Danielson BG, Grefberg N, Berne C. Vitamin A lossesduring continuous ambulatory peritoneal dialysis. Nephron. 1985;41:179-83. 3. Pahor D. Retinal light sensitivity in haemodialysis patients. Eye. 2003;17:177-82. 4. Stewart WK, Fleming LW. Plasma retinol and retinol binding protein concentrations in patients on maintenance haemodialysis with and without vitamin A supplements. Nephron. 1982;30:15-21.
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
Correspondence 5. Stein G, Schöne S, Geinitz D, et al. No tissue level abnormality of vitamin A concentration despite elevated serum vitamin A of uremic patients. Clin Nephrol. 1986;25:87-93. 6. Yatzidis H, Digenis P, Fountas P. Hypervitaminosis A accompanying advanced chronic renal failure. Br Med J. 1975;3:352-3.
Clinicopathologic case reports of Alternaria and Fusarium keratitis in Canada Fungal keratitis is prevalent in tropical environments, making up 35% of all keratitis cases in Florida.1 However, few cases have been reported in more temperate regions such as Canada.1–3 In this article, we present 2 Canadian farmers who experienced keratitis involving a dematiaceous fungus, Alternaria alternata, and a Fusarium species, respectively.
Can J Ophthalmol 2013;48:e148–e151 0008-4182/13/$-see front matter & 2013 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2013.06.006
CASE 1 In a farming accident, a 49-year-old male sustained a severe alkali injury to his left eye (OS), reducing his visual acuity to 20/120 (Fig. 1A). He developed a hypopyon, which slowly improved on topical 1% prednisolone acetate and oral prednisone (50 mg daily) while continuing with prophylactic topical moxifloxacin and tobramycin. His corneal opacification progressed to an inferior descemetocele. Four months after presentation, he received a Boston keratoprosthesis (k-pro).
Fig. 1 — A, Corneal ulceration after alkaline chemical burns to the left eye. B, One month after k-pro implantation with the infectious process infiltrating into the graft material. C, The corneal specimen is severely necrotic with irregular thinning of the inflamed stroma (hematoxylin and eosin, 25 original magnification). D, The Grocott–Gomori methenamine silver stain (GMS) shows numerous filamentous fungi at all levels predominantly anteriorly in the necrotic central stroma (200 original magnification). E, Higher magnification of septated fungi (GMS, 640 original magnification). F, Tease mount of a 72-hour culture growth that has been stained with lactophenol cotton blue, showing large, brown pigmented, muriform macroconidia occurring in short chains that is characteristic of Alternaria species (640 original magnification). CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
e151
