Vol. 114, No. 3
Letters to The Journal
369
3. Moore, M. B., Harrington, J., and McCulley, J. P.: Floppy eyelid syndrome management including surgery. Ophthalmology 93:184, 1986.
Fungal Keratitis After Radial Keratotomy Steven L. Maskin, M.D., and Eduardo Alfonso, M.D. Bascom Palmer Eye Institute, Department of Oph thalmology, University of Miami School of Medicine. Inquiries to Eduardo Alfonso, M.D., Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101. A 35-year-old woman had a history of Crohn's disease that was treated with sulfasalazine. The patient had six-incisional radial kera totomy of both eyes; the right eye in October 1990, and the left eye in January 1991. Postoperatively the right eye had done well. However, two weeks postoperatively, the left eye became red and irritated while on a regimen of antibiot ic and corticosteroid drops. The surgeon noted an infiltrate in the central aspect of the 5 o'clock incision. The patient was treated with topical fortified cefazolin, fortified tobramycin, and dexamethasone without improvement. Cul tures yielded no growth. On March 6, 1991, the patient was referred to a corneal specialist be cause of continued irritation and pain. A diag nosis of crystalline keratopathy was made. The wound at the 5 o'clock incision was irrigated with vancomycin (50 mg/ml). Vancomycin (50 mg) and gentamicin (40 mg) were injected subconjunctivally, and the patient was given topi cal fortified cefazolin, fortified tobramycin, Neosporin, and fluorometholone 0.25%. Re peat cultures yielded no growth. On March 18, 1991, she was referred to Bascom Palmer Eye Institute for examination and treatment of per sistent keratitis. Visual acuity was 20/30 in the left eye. There was moderate bulbar conjunctival injection with ciliary flush. The 5 o'clock incision had a mid to deep stromal feathery white infiltrate with overlying epithelial defect (Figure). There were small keratic precipitates on the underlying endothelium. The anterior chamber was not inflamed. Tension was 16 mm Hg by pneumotonometry. The posterior seg ment was normal. The patient was admitted to the hospital after undergoing corneal scraping for smears and culture. Topical ciprofloxacin
Figure (Maskin and Alfonso). Stromal infiltrate with overlying epithelial defect at the 5 o'clock inci sion, three months after radial keratotomy. every 30 minutes was started. Cultures were positive for Candida parapsilosis. The patient was then treated with topical amphotericin B (0.5%), one drop every 30 minutes, and ketoconazole, 200 mg orally three times a day. The patient had daily epithelial scrapings while in the hospital to provide optimal penetration of the amphotericin B to the deep corneal stroma. By the fourth day of therapy, there was marked improvement in symptoms, as well as a de crease of the infiltrate. On follow-up examina tion, approximately one month later, she was symptom-free, with a best-corrected visual acuity of 20/20. The infiltrate was less dense with an intact epithelium. Amphotericin B, 0.5%, was tapered to every four hours and she continued the ketoconazole, 200 mg orally three times a day. Infectious keratitis is one of the most visually significant complications to occur after radial keratotomy surgery. Maintenance of good vi sion (greater than 20/40) relies on early identi fication and institution of appropriate thera py.1,2 Bacterial keratitis may occur early, within the first few postoperative weeks, or late.1,2 Early-onset cases are mainly caused by grampositive cocci (60%), whereas the majority of late-onset cases (62%) are caused by gramnegative rods. 2 The early onset of fungàl keratitis after radial keratotomy in our patient suggests the inoculum occurred during the in traoperative or early postoperative period. The routine use of postoperative topical corticosteroids may dispose the wounded cornea to growth of fungal organisms. Our patient had no
370
AMERICAN JOURNAL OF OPHTHALMOLOGY
September, 1992
known agricultural or other direct exposure to fungal elements. Infectious keratitis after radial keratotomy may be caused by nonbacterial mi crobes as in all cases of microbial keratitis, and it warrants comprehensive cultures.
References 1. Rashid, E. R., and Waring, G. O.: Complications of radial and transverse keratotomy. Surv. Ophthalmol. 34:73, 1989. 2. Matoba, A. Y., Torres, J., Wilhelmus, K. R., Hamill, M. B., and Jones, D. B.: Bacterial keratitis after radial keratotomy. Ophthalmology 96:1171, 1989.
Sporothrix schenckii Scleritis Isabelle Brunette, M.D., and R. Doyle Stulting, M.D. Emory Eye Center, Emory University School of Medi cine. Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York. Inquiries to R. Doyle Stulting, M.D., Emory Eye Center, 1327 Clifton Rd. N.E., Atlanta, GA 30322. A 40-year-old healthy white man was struck in the left eye by a flying chip of wood on Dec. 21, 1987. Two months later, his eye became progressively red and painful and a diagnosis of episcleritis was made on Feb. 2, 1988. After failure to respond to treatment with topical dexamethasone, he was referred to us for fur ther examination. When first seen at the Emory Eye Center on April 4, 1988, the patient's visual acuity was R.E.: 20/15 and L.E.: 20/20. The left eye showed moderate conjunctival injection and chemosis. An area of scierai necrosis was pres ent near the nasal corneoscleral limbus at the 9 o'clock meridian (Fig. 1). No foreign body was found. Gram stain of a scraping from the necrotic sclera disclosed thick-walled yeast forms (Fig. 2). Treatment was begun with miconazole, 10 mg/ml every hour topically, and 15 mg subconjunctivally. By April 18, inflammation had progressed and the eye had become more painful. Miconazole was replaced by amphotericin B topically (2.5 mg/ml every hour), intra venously (0.25 m g / k g of body weight/day in-
Fig. 1 (Brunette and Stulting). Sporothrix schenckii scleritis. An area of scierai necrosis was present near the nasal corneoscleral limbus at the 9 o'clock merid ian. creased to maximal daily doses of 0.6 m g / k g of body weight), and subconjunctivally (0.75 mg every other day for three doses). On April 21, the Centers for Disease Control identified the organism as Sporothrix schenckii. Administra tion of a saturated solution of potassium iodide was started at ten drops orally three times a day, increasing by two drops every other day up to a daily dose of 24 drops three times a day. By April 29, the scierai ulcer bed was clean, firm, vascularized, and 40% of normal thickness. On June 1, all medications were discontinued. Since then, the eye has been uninflamed and visual acuity is 20/20. Sporothrix schenckii is a dimorphic fungus. Diagnosis is made by cultures on Sabouraud's agar where cream to black, folded colonies develop within three to five days. The fungus lives as a saprophyte on vegetation. Typically, after an incubation period of three to 40 weeks, a red papule appears on the hand or other exposed body surface. It progresses to a pustule and ulcerates. The infection may remain local ized or more frequently, spreads along the lymphatics, resulting in a series of subcutane ous nontender nodules that may ulcerate. This lymphocutaneous form is far more frequent than the pulmonary form (resulting from inha lation of airborne spores) and the hematogenously disseminated form of sporotrichosis. Sporotrichosis is a potentially lethal infection. Ocular infections are most frequently limited to eyelids and conjunctiva, although severe infection may gain access to any part of the eye, either by exogenous or endogenous routes. In 1928, De Caralt 1 described a yellowish
Letters to The Journal
369
3. Moore, M. B., Harrington, J., and McCulley, J. P.: Floppy eyelid syndrome management including surgery. Ophthalmology 93:184, 1986.
Fungal Keratitis After Radial Keratotomy Steven L. Maskin, M.D., and Eduardo Alfonso, M.D. Bascom Palmer Eye Institute, Department of Oph thalmology, University of Miami School of Medicine. Inquiries to Eduardo Alfonso, M.D., Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101. A 35-year-old woman had a history of Crohn's disease that was treated with sulfasalazine. The patient had six-incisional radial kera totomy of both eyes; the right eye in October 1990, and the left eye in January 1991. Postoperatively the right eye had done well. However, two weeks postoperatively, the left eye became red and irritated while on a regimen of antibiot ic and corticosteroid drops. The surgeon noted an infiltrate in the central aspect of the 5 o'clock incision. The patient was treated with topical fortified cefazolin, fortified tobramycin, and dexamethasone without improvement. Cul tures yielded no growth. On March 6, 1991, the patient was referred to a corneal specialist be cause of continued irritation and pain. A diag nosis of crystalline keratopathy was made. The wound at the 5 o'clock incision was irrigated with vancomycin (50 mg/ml). Vancomycin (50 mg) and gentamicin (40 mg) were injected subconjunctivally, and the patient was given topi cal fortified cefazolin, fortified tobramycin, Neosporin, and fluorometholone 0.25%. Re peat cultures yielded no growth. On March 18, 1991, she was referred to Bascom Palmer Eye Institute for examination and treatment of per sistent keratitis. Visual acuity was 20/30 in the left eye. There was moderate bulbar conjunctival injection with ciliary flush. The 5 o'clock incision had a mid to deep stromal feathery white infiltrate with overlying epithelial defect (Figure). There were small keratic precipitates on the underlying endothelium. The anterior chamber was not inflamed. Tension was 16 mm Hg by pneumotonometry. The posterior seg ment was normal. The patient was admitted to the hospital after undergoing corneal scraping for smears and culture. Topical ciprofloxacin
Figure (Maskin and Alfonso). Stromal infiltrate with overlying epithelial defect at the 5 o'clock inci sion, three months after radial keratotomy. every 30 minutes was started. Cultures were positive for Candida parapsilosis. The patient was then treated with topical amphotericin B (0.5%), one drop every 30 minutes, and ketoconazole, 200 mg orally three times a day. The patient had daily epithelial scrapings while in the hospital to provide optimal penetration of the amphotericin B to the deep corneal stroma. By the fourth day of therapy, there was marked improvement in symptoms, as well as a de crease of the infiltrate. On follow-up examina tion, approximately one month later, she was symptom-free, with a best-corrected visual acuity of 20/20. The infiltrate was less dense with an intact epithelium. Amphotericin B, 0.5%, was tapered to every four hours and she continued the ketoconazole, 200 mg orally three times a day. Infectious keratitis is one of the most visually significant complications to occur after radial keratotomy surgery. Maintenance of good vi sion (greater than 20/40) relies on early identi fication and institution of appropriate thera py.1,2 Bacterial keratitis may occur early, within the first few postoperative weeks, or late.1,2 Early-onset cases are mainly caused by grampositive cocci (60%), whereas the majority of late-onset cases (62%) are caused by gramnegative rods. 2 The early onset of fungàl keratitis after radial keratotomy in our patient suggests the inoculum occurred during the in traoperative or early postoperative period. The routine use of postoperative topical corticosteroids may dispose the wounded cornea to growth of fungal organisms. Our patient had no
370
AMERICAN JOURNAL OF OPHTHALMOLOGY
September, 1992
known agricultural or other direct exposure to fungal elements. Infectious keratitis after radial keratotomy may be caused by nonbacterial mi crobes as in all cases of microbial keratitis, and it warrants comprehensive cultures.
References 1. Rashid, E. R., and Waring, G. O.: Complications of radial and transverse keratotomy. Surv. Ophthalmol. 34:73, 1989. 2. Matoba, A. Y., Torres, J., Wilhelmus, K. R., Hamill, M. B., and Jones, D. B.: Bacterial keratitis after radial keratotomy. Ophthalmology 96:1171, 1989.
Sporothrix schenckii Scleritis Isabelle Brunette, M.D., and R. Doyle Stulting, M.D. Emory Eye Center, Emory University School of Medi cine. Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York. Inquiries to R. Doyle Stulting, M.D., Emory Eye Center, 1327 Clifton Rd. N.E., Atlanta, GA 30322. A 40-year-old healthy white man was struck in the left eye by a flying chip of wood on Dec. 21, 1987. Two months later, his eye became progressively red and painful and a diagnosis of episcleritis was made on Feb. 2, 1988. After failure to respond to treatment with topical dexamethasone, he was referred to us for fur ther examination. When first seen at the Emory Eye Center on April 4, 1988, the patient's visual acuity was R.E.: 20/15 and L.E.: 20/20. The left eye showed moderate conjunctival injection and chemosis. An area of scierai necrosis was pres ent near the nasal corneoscleral limbus at the 9 o'clock meridian (Fig. 1). No foreign body was found. Gram stain of a scraping from the necrotic sclera disclosed thick-walled yeast forms (Fig. 2). Treatment was begun with miconazole, 10 mg/ml every hour topically, and 15 mg subconjunctivally. By April 18, inflammation had progressed and the eye had become more painful. Miconazole was replaced by amphotericin B topically (2.5 mg/ml every hour), intra venously (0.25 m g / k g of body weight/day in-
Fig. 1 (Brunette and Stulting). Sporothrix schenckii scleritis. An area of scierai necrosis was present near the nasal corneoscleral limbus at the 9 o'clock merid ian. creased to maximal daily doses of 0.6 m g / k g of body weight), and subconjunctivally (0.75 mg every other day for three doses). On April 21, the Centers for Disease Control identified the organism as Sporothrix schenckii. Administra tion of a saturated solution of potassium iodide was started at ten drops orally three times a day, increasing by two drops every other day up to a daily dose of 24 drops three times a day. By April 29, the scierai ulcer bed was clean, firm, vascularized, and 40% of normal thickness. On June 1, all medications were discontinued. Since then, the eye has been uninflamed and visual acuity is 20/20. Sporothrix schenckii is a dimorphic fungus. Diagnosis is made by cultures on Sabouraud's agar where cream to black, folded colonies develop within three to five days. The fungus lives as a saprophyte on vegetation. Typically, after an incubation period of three to 40 weeks, a red papule appears on the hand or other exposed body surface. It progresses to a pustule and ulcerates. The infection may remain local ized or more frequently, spreads along the lymphatics, resulting in a series of subcutane ous nontender nodules that may ulcerate. This lymphocutaneous form is far more frequent than the pulmonary form (resulting from inha lation of airborne spores) and the hematogenously disseminated form of sporotrichosis. Sporotrichosis is a potentially lethal infection. Ocular infections are most frequently limited to eyelids and conjunctiva, although severe infection may gain access to any part of the eye, either by exogenous or endogenous routes. In 1928, De Caralt 1 described a yellowish
