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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 59  |  Issue : 3  |  Page : 301-303

Fungal scleritis following evisceration


1 Department of Ophthalmology, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Ophthalmology, KEM Hospital, Pune, Maharashtra, India

Date of Submission18-Apr-2021
Date of Acceptance27-Jun-2021
Date of Web Publication09-Sep-2021

Correspondence Address:
Dr. Aalia Rasool Sufi
Department of Ophthalmology, Government Medical College, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_43_21

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  Abstract 


Infection of the sclera poses a therapeutic challenge due to its poor vascularity. Herein, we describe a case of fungal scleritis following evisceration in an immunocompetent man. Aggressive multidrug medical treatment was combined with enucleation to eliminate the infection. Thus, a multipronged approach is to be adopted for successful outcome and the prevention of complications.

Keywords: Aspergillosis, enucleation, evisceration, fungal scleritis, voriconazole


How to cite this article:
Sufi AR, Gaikwad N, Shah A, Wani J. Fungal scleritis following evisceration. TNOA J Ophthalmic Sci Res 2021;59:301-3

How to cite this URL:
Sufi AR, Gaikwad N, Shah A, Wani J. Fungal scleritis following evisceration. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Sep 21];59:301-3. Available from: https://www.tnoajosr.com/text.asp?2021/59/3/301/325736




  Introduction Top


Inflammatory disease of the sclera is mostly attributed to underlying immune-mediated disorders; however, in 4%–18% of cases, it has an infective etiology.[1] Most cases of infectious scleritis follow surgery, trauma, or extension from adjacent infections such as keratitis, or panophthalmitis.[2],[3],[4] Few cases of fungal scleritis have been reported. These mycotic infections pose considerable diagnostic and therapeutic challenges, and the selection of effective, and nontoxic medical therapy is a difficult task. Most often, a combined approach using both medical and surgical interventions is necessary for the elimination of infection and prevention of further complications. Herein, we describe a case of fungal scleritis following evisceration.


  Case Report Top


A 60-year-old male, a farmer by profession, presented to the ophthalmology outpatient department for rehabilitation of the left eye eviscerated elsewhere for a perforated corneal ulcer 40 days back.

Although the patient was asymptomatic, on examination of the left eye, we noticed a localized 4 mm × 5 mm whitish ball-like mass resembling a mold on the sclera within the eviscerated socket. The surrounding sclera was healthy with no congestion or discharge. The right eye was normal. Scrapings of the mass were sent for Grams staining and potassium hydroxide (KOH) which revealed fungal hyphae. Thorough betadine washes of the socket were done and the patient was started on natamycin 5% eye drops and voriconazole 1% eye drops. Subsequently, growth of Aspergillus flavus was seen on culture and the patient was started on oral voriconazole 200 mg BD. However, within 5 days, the patient rapidly deteriorated. There was inflammation conjunctiva and the whole residual scleral shell [Figure 1]. Thus, the patient was started on intravenous (IV) liposomal amphotericin B (L-AMB) 1 mg/kg/day after consulting a physician. Systemic monitoring of the patient was undertaken. Immune status of the patient was found to be normal. Regular surgical debridement was done. However, the patient did not show any improvement with further increase in inflammation and infection obliterating the ocular cavity [Figure 2]. Noncontract computed tomography was done which showed normal retrobulbar space with no adjacent bone invasion. The sinuses on the left side were normal thus ruling out any extension from the sinuses [Figure 3] with an incidental finding of the right side maxillary polyp. In view of the localized pathology and to prevent further involvement of the orbit, we planned enucleation. The enucleated tissue was sent for histopathology and microbiology which confirmed A. flavus. The orbit was free of infection [Figure 4] and the patient continued with IV AMB for 5 days after enucleation. However, he developed renal complications due to AMB, thus was shifted to oral voriconazole 200 mg BD for 2 months then voriconazole 200 mg OD for 1 month. The patient showed a healthy socket with no evidence of re-infection 3 months postenucleation.
Figure 1: Fungal scleritis following evisceration

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Figure 2: Deterioration of the disease with obliteration of the ocular cavity

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Figure 3: Computed tomography scan of the patient showing localized pathology with normal sinuses, retrobulbar space with no adjacent bone invasion

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Figure 4: Orbit 1 week postenucleation with no signs of infection

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  Discussion Top


Aspergillus species are commonly found in soil, decaying organic matter, and the indoor environment. The two most common pathogens in humans are A. flavus and Aspergillus fumigatus. A. flavus causes an invasive granulomatous infection, with rapid deterioration if treated inadequately. There may be a fulminate immune response with a centrifugal invasion of adjacent tissues, vasculature, and bone. Involvement of the orbit may result in orbital apex syndrome, necrotizing angiitis, mycotic aneurysms, thrombosis, erosion of the orbit, systemic dissemination, and direct invasion of the central nervous system thereby increasing the mortality rate manifold. [5],[6],[7] Thus arises the need for prompt treatment.

Our case developed fungal scleritis post evisceration. After an asymptomatic period of 40 days, the patient developed a socket infection. There could be two possibilities, either it was an extension of the previous disease or a new invasion of the socket. The Aspergillus species are commonly found in the soil and decaying organic matter. It often prefers a warm moist environment and the socket serves as an incubator for these organisms. Our patient, a farmer with an open socket was thus predisposed to this possibility.

Medical treatment of fungal scleritis is limited by poor drug penetration due to the poor vascularity of the sclera, and also due to the limited number of antifungal agents and the adverse side effects of the drugs. AMB is considered the treatment of choice for severe ophthalmic mycoses.[8] However, AMB has numerous side effects, including irreversible nephrotoxicity, and as a result, is often poorly tolerated. In recent times, voriconazole has emerged as the usual antifungal for invasive aspergillosis. It has favorable penetration, less systemic side effects than AMB, thus is better tolerated for maintenance therapy.[9],[10] Duration of therapy in the published literature appears to require a minimum course of 3 months to a year.

Surgical methods are important means of controlling fungal scleritis unresponsive to medical treatment. In addition, they also reduce the duration of treatment and adverse effects of anti-fungal drugs. Although our patient was started on prompt medical treatment; however, rapid deterioration and development of adverse effects to AMB, prompted us to resort to enucleation to limit the spread of the disease to the sclera only and prevent the involvement of the orbit and beyond thus preventing the development of further complications. Thus, our case highlights the importance of a timely multipronged treatment approach. We would also like to advocate an early closure of the sclera with the rehabilitation of the socket with a ball implant postevisceration to prevent the empty socket acting as a conduit for infection as was seen in this patient. Furthermore, the importance of patient education regarding the maintenance of hygiene of the socket postevisceration cannot be understated.

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.
Schwam BL, Raizman MB. Scleritis. In: Krachmer JH, Mannis MJ, Holland EJ, editors. Cornea. St. Louis, MO: Mosby, Inc; 1997. p. 1479-91.  Back to cited text no. 1
    
2.
Garg P, Mahesh S, Bansal AK, Gopinathan U, Rao GN. Fungal infection of sutureless self-sealing incision for cataract surgery. Ophthalmology 2003;110:2173-7.  Back to cited text no. 2
    
3.
Huang FC, Huang SP, Tseng SH. Management of infectious scleritis after pterygium excision. Cornea 2000;19:34-9.  Back to cited text no. 3
    
4.
Kim JE, Perkins SL, Harris GJ. Voriconazole treatment of fungal scleritis and epibulbar abscess resulting from scleral buckle infection. Arch Ophthalmol 2003;121:735-7.  Back to cited text no. 4
    
5.
Levin LA, Avery R, Shore JW, Woog JJ, Baker AS. The spectrum of orbital aspergillosis: A clinicopathological review. Surv Ophthalmol 1996;41:142-54.  Back to cited text no. 5
    
6.
Matsuo T, Notohara K, Yamadori I. Aspergillosis causing bilateral optic neuritis and later orbital apex syndrome. Jpn J Ophthalmol 2005;49:430-1.  Back to cited text no. 6
    
7.
Turgut M, Ozsunar Y, Oncü S, Akyüz O, Ertuğrul MB, Tekin C, et al. Invasive fungal granuloma of the brain caused by Aspergillus fumigatus: A case report and review of the literature. Surg Neurol 2008;69:169-74.  Back to cited text no. 7
    
8.
Thomas PA. Current perspectives on ophthalmic mycoses. Clin Microbiol Rev 2003;16:730-97.  Back to cited text no. 8
    
9.
Sasindran V, Ravikumar A, Senthil. Orbital apex syndrome in a child. Indian J Otolaryngol Head Neck Surg 2008;60:62-5.  Back to cited text no. 9
    
10.
Herbrecht R, Denning DW, Patterson TF, Bennett JE, Greene RE, Oestmann JW, et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med 2002;347:408-15.  Back to cited text no. 10
    


    Figures

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



 

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