November 2013 Brief Communications 669
References
1. Brown GC, Shields JA. Cilioretinal arteries and retinal arterial occlusion. Arch Ophthalmol 1979;97:84‑92.
2. LaMonica CB, Foye GJ, Silberman L. A case of sudden retinal artery occlusion and blindness in pregnancy. Obstet Gynecol 1987;69:433‑5.
3. Mangat HS. Retinal artery occlusion. Surv Ophthalmol 1995;40:145‑56.
4. Cugati S, Varma DD, Chen CS, Lee AW. Treatment options for central retinal artery occlusion. Curr Treat Options Neurol 2013;15:63‑77.
5. Biousse V, Calvetti O, Bruce BB, Newman NJ. Thrombolysis for central retinal artery occlusion. J Neuroophthalmol 2007;27:215‑30.
6. Noble J, Weizblit N, Baerlocher MO, Eng KT. Intra‑arterial thrombolysis for central retinal artery occlusion: A systematic review. Br J Ophthalmol 2008;92:588‑93.
7. Schumacher M, Schmidt D, Jurklies B, Gall C, Wanke I, Schmoor C,
et al. Central retinal artery occlusion: Local intra‑arterial fibrinolysis versus conservative treatment, a multicenter randomized trial.
Ophthalmology 2010;117:1367‑75.
8. Chen CS, Lee AW, Campbell B, Lee T, Paine M, Fraser C, et al. Efficacy of intravenous tissue‑type plasminogen activator in central retinal artery occlusion: Report from a randomized, controlled trial. Stroke 2011;42:2229‑34.
Cite this article as: Caglar C, Caglar Z, Gul A. The central retinal artery occlusion in the right eye followed by a branch retinal artery occlusion in the left eye four days later. Indian J Ophthalmol 2013;61:667-9.
Source of Support: Nil. Conflict of Interest: None declared.
Successful treatment of Fusarium
keratitis after photo refractive
keratectomy
Gian Maria Cavallini, Pietro Ducange,
Veronica Volante, Caterina Benatti
A 39‑year‑old woman presented to our hospital with a history of photorefractive keratectomy (PRK), performed two weeks prior; slit‑lamp examination revealed diffuse conjunctival congestion, corneal ulcer and stromal infiltration. After 5 days of antifungal and antibacteric treatment, the infiltrate progressively increased so that a therapeutic penetrating keratoplasty was necessary. The microbiological analyses revealed the presence of fungal filaments. Twenty days after surgery the patient had recurrent fungal infiltrate in the donor cornea with wound dehiscence. We performed a second penetrating keratoplasty. With the matrix‑assisted‑laser‑desorption‑ionization‑time‑of‑flight analysis (MALDI‑TOF) we identified a Fusarium solani. Intravenous amphothericine B, a combination of intracameral and intrastromal voriconazole and intracameral amphotericine B were administered. After 6 months from the last surgery the infection
Institute of Ophthalmology, University of Modena and Reggio Emilia, Modena, Italy
Correspondence to: Prof. Gian Maria Cavallini, Struttura Complessa di Oftalmologia, Azienda Ospedaliero‑Universitaria di Modena Policlinico, Via del Pozzo 71, 41100, Modena, Italy. E‑mail: cavallini. gianmaria@unimore.it
Manuscript received: 12.11.12; Revision accepted: 22.02.13 Access this article online
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was eradicated. The management of fungal keratitis after PRK depends on many factors: In our experience, a prompt keratoplasty and the use of intracameral antifungal medication proved to be very effective.
Key words: Fusarium, keratitis, photo refractive keratectomy Fusarium species are common organisms that are present in soil, water and plants. These fungi are more frequent in tropical and temperate areas,[1] and are the most well‑known agents
of fungal keratitis world‑wide, causing up to 32% of reported infections;[2] in USA Fusarium spp. are documented as the most
common cause of keratitis.[3]
Most infections are often preceded by trauma. Other risk factors include the use of antibiotics and corticosteroids, pre‑existing eye diseases, foreign bodies’ surgery and the use of contact lenses. Among Fusarium species, F. solani, F. oxysporum and F. moniliforme are the most frequently implicated in human infections.[2]
Case Report
A 39‑year‑old woman presented to our hospital with a history of photorefractive keratectomy (PRK), performed two weeks prior. She complained severe visual loss, photophobia, redness and pain in right eye.
The patient was receiving therapy with topical steroids and antibiotic eye drops. The best corrected visual acuity (BCVA) of the affected eye was limited to hand motion. Slit lamp examinations revealed diffuse conjunctival congestion and a corneal ulcer with stromal infiltration [Fig. 1a].
The ulcer bed and edges were scraped and were sent for bacteriological and mycological examination analysis.
Treatment with corticosteroid eye drops was suspended and the patient was started on the following drugs: Topical fortified 5% vancomicin, tobramicin 0.3%, moxifloxacin 0.5%, amphotericin B 0.15% at 4 h intervals; systemic antifungal and antibacteric drugs consisted of oral itraconazole at a dose of 200 mg daily with oral ciprofloxacin 1g daily, and intramuscolar ceftriaxone 1 g daily respectively.
After two days the cornea revealed a full thickness infiltrate with 1 mm hypopyon [Fig. 1b]. The infiltrate and the hypopyon
670 Indian Journal of Ophthalmology Vol. 61 No. 11
Figure 1: (a) Diffuse conjunctival congestion and corneal ulcer with
stromal infiltration, (b) large full thickness infiltrate with 1 mm hypopyon, (c) endothelial dusting, aqueous flare and cells
c
b a
Figure 2: (a) Eye redness, endothelial dusting, aqueous flare and cells,
(b) fungal infiltrate in with wound dehiscence, (c) eradication of infection
a b
c
progressively increased in size. After 5 days, the patient underwent a therapeutic penetrating keratoplasty with an 8‑mm graft on a 7.75‑mm bed using Barron Corneal Trephine. The explanted cornea was sent to the microbiology laboratory for further testing.
Post‑surgery treatment consisted in topical norfloxacin 0.3% (6 times per day) and amphotericin B (4 times per day); systemic ciprofloxacin 1 g daily, ceftriaxone 1 g daily, itraconazole 200 mg daily and intramuscolar metilprednisolone 20 mg daily [Fig. 1].
After 8 days, the culture of corneal scraping revealed the presence of fungal filaments. We decided in agreement with the infectious disease specialist, to add therapy with oral voriconazole, (800 mg per day on the first day, followed by 400 mg per day on successive days) and topical amphothericin B eye drops 6 times per day. The donor cornea and anterior chamber remained free from infiltrates until day 12, after keratoplasty, when the patient showed eye redness, pain, 1/50 of visual acuity, endothelial dusting and aqueous flare and cells [Figs. 1c and 2a]. Oral voriconazole was changed to intravenous formulation, 8 mg/Kg twice per day.
Twenty days after surgery the patient had recurrent fungal infiltrate in the donor cornea with wound dehiscence [Fig. 2b]. We decided to perform a second penetrating keratoplasty.
Results
Because of the high degree of homology in culture between Fusarium solani or oxysporum, it has been difficult to rule out the two similar opportunistic pathogens from the biopsies performed for microbiological analysis. In order to have a proven and rapid differential diagnosis we sent biopsy material to the Institute of Microbiology of Bellinzona (Switzerland), where a matrix‑assisted laser desorption ionization‑time‑of‑flight analysis (MALDI‑TOF) has been performed.
The fungal isolate was identified as Fusarium solani, occurring in both the first and second explanted corneas. After specific antifungal sensitivity testing, we decided to start the patient on the following agents: 3 mg/Kg twice a day of
intravenous amphothericin pB; netilmycin 0.3%, moxifloxacin 0.5%, voriconazole 1% (drops every 2 h) and diclofenac 0.1% (drops every 8 h).
During the following days, we performed a combination of intracameral/intrastromal voriconazole (50 μg/0.1 ml) in addition to intracameral amphothericine B (10 microg/0.1 mL), in three different administrations.[4,5]
After 6 m from the last surgery the infection was eradicated, the donor cornea was clear, and the BCVA was 7/10 [Fig. 2c].
Discussion
In this case report we describe the therapeutic management of fungal keratitis post PRK.
The incidence of infectious complications post PRK is relatively low and the pathogens primarily involved are Gram‑positive organisms.[6] To our knowledge, only few cases
of fungal keratitis are reported.[7,8]
The use of bandage contact lens (BCL) and topical steroid therapy, provided in the postoperative course of the PRK together with the breakdown of the barrier function of the corneal epithelium, may cause a predisposition to fungal corneal infection. A variety of factors can determine the course of a fungal keratitis such as early diagnosis, sensitivity to drug therapy and virulence of the fungus.
In our case, the natural history of the infection was influenced by appropriate timing of intervention; in fact, the choice to perform a penetrating keratoplasty proved to be effective in containing the infection and preventing corneal perforation. Our patient had a recurrence of the infection that can be explained by the delay in starting the specific therapy with voriconazole, [due to the time required for microbial culture (8 days)] and the need to perform the MALDI‑TOF in order to identify the species of Fusarium.
The long use of topical steroid after PRK might be another cause of fungal infection recurrence after the first PRK, as reported in the literature.[9] The presence of hypopyon before
surgery has also been reported as a risk factor for recurrent fungal infection after PK.[10]
November 2013 Brief Communications 671
Conclusion
The management of fungal keratitis after PRK depends on many factors: In our experience, the decision of performing a prompt keratoplasty was aimed at reducing the corneal infection in the first occurrence, and to solve it in the second manifestation. Finally the use of intracameral antifungal medication proved to be very effective in avoiding the recurrence of infection.
References
1. Klont RR, Eggink CA, Rijs AJ, Wesseling P, Verweij PE. Successful treatment of Fusarium keratitis with cornea transplantation and topical and systemic voriconazole. Clin Infect Dis 2005;15:40:110‑2.
2. Dignani MC, Anaissie E. Human fusariosis. Clin Microbiol Infect 2004;10:67‑75.
3. Jones DB, Forster FK, Rebell G. Fusarium solani keratitis treated with natamycin (pimaricin): Eighteen consecutive cases. Arch Ophthalmol 1972;88:147‑54.
4. Yoon KC, Jeong IY, Im SK, Chae HJ, Yang SY. Therapeutic effect of intracameral amphotericin B injection in the treatment of fungal keratitis. Cornea 2007;26:814‑8.
5. Haddad RS, El‑Mollayess GM. Combination of intracameral and intrastromal voriconazole in the treatment of recalcitrant Acremonium fungal keratitis. Middle East Afr J Ophthalmol 2012;19:265‑8.
6. Wroblewski KJ, Pasternak JF, Bower KS, Schallhorn SC, Hubickey WJ, Harrison CE, et al. Infectious keratitis after photorefractive keratectomy in the United States army and navy. Ophthalmology 2006;113:520‑5.
7. Kouyoumdjian GA, Forstot SL, Durairaj VD, Damiano RE. Infectious keratitis after laser refractive surgery. Ophthalmology 2001;108:1266‑8.
8. Periman LM, Harrison DA, Kim J. Fungal keratitis after photorefractive keratectomy: Delayed diagnosis and treatment in a comanaged setting. J Refract Surg 2003;19:364‑6.
9. Sharma DP, Sharma S, Wilkins MR. Microbial keratitis after corneal laser refractive surgery. Future Microbiol 2011;6:819‑31.
10. Shi W, Wang T, Xie L, Li S, Gao H, Liu J et al. Risk factors, clinical features, and outcomes of recurrent fungal keratitis after corneal transplantation. Ophthalmology 2010;117:890‑6.
Cite this article as: Cavallini GM, Ducange P, Volante V, Benatti C. Successful treatment of Fusarium keratitis after photo refractive keratectomy. Indian J Ophthalmol 2013;61:669-71.
Source of Support: Nil. Conflict of Interest: None declared.
Department of Ophthalmology, Government Medical College, Kozhikode, Kerala, India
Correspondence to: Dr. Rose Mary Tomy, W/o Dr. Frijo Jose A, Aloor House Marathancode P, Thrissur ‑ 680 604, Kerala, India. E‑mail: rosefrijo@gmail.com
Manuscript received: 04.05.12; Revision accepted: 02.07.13
Ophthalmomyiasis externa by
Musca domestica in a case of orbital
metastasis
Rose Mary Tomy, Padma B Prabhu
Infestation of the living tissues of the eye, ocular adnexae or orbit by larvae of flies of the order Diptera is known as ophthalmomyiasis. Ophthalmomyiasis externa is a limited superficial infestation of external ocular structures such as conjunctiva and adnexae. A case of follicular carcinoma thyroid with orbital metastasis presenting as ophthalmomyiasis externa is reported. The patient presented with foul smelling ulcers of the medial and lateral orbital walls of the right eye extending into the lids and nose, teeming with maggots. Computerized Tomography (CT) showed widespread
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bone destruction with extension into surrounding sinuses. Over 200 maggots were manually removed after immobilisation with turpentine oil instillation. Entomological examination showed it to be a case of accidental myiasis caused by the common housefly Musca domestica. The patient was managed conservatively and the ulcer cavities filled up with healthy granulation tissue. This case is presented on account of its rarity.
Key words: Accidental myiasis, maggot, Musca domestica, ophthalmomyiasis, turpentine oil
A case of follicular carcinoma thyroid with orbital metastasis presenting as ophthalmomyiasis externa is reported. Over 200 Musca domestica larvae were removed after turpentine oil instillation. The debilitated state of the orbital tissues coupled with close proximity to housefly infestation are speculated to have resulted in ophthalmomyiasisInfestation of the living tissues of the eye, ocular adnexae or orbit by larvae of flies of the order Diptera is known as ophthalmomyiasis. Myiasis of the face occurs in 1% of cases.[1] Ocular myiasis being still fewer,
is reported here for its rarity
Case Report
A 70‑year‑old male presented with a foul smelling and discharging ulcer around the right eye of seven days duration. He complained of a crawling sensation over the area for the past two days.
A diabetic, he was diagnosed with follicular carcinoma thyroid one year ago. He refused therapy, but came back after four months of alternative medicine treatment. In view of widespread metastasis then, he underwent chemotherapy. During the chemo, he developed painful swelling of the right eye with loss of vision and was subsequently lost to follow‑up. He remained largely symptom free till the present complaints.
