Original Article Risk Factors and Clinical Outcomes of Bacterial and Fungal Scleritis at a Tertiary Eye Care Hospital Jagadesh C. Reddy, Somasheila I. Murthy1, Ashok K. Reddy2, Prashant Garg Access this article online

ABSTRACT Purpose: The aim was to analyze demographics, risk factors, pathogenic organisms, and clinical outcome in cases with microbiologically proven bacterial or fungal scleritis. Materials and Methods: Retrospective review of all the medical records of patients with microbiologically proven infectious scleritis examined from March 2005 to December 2009 in the cornea services of L. V. Prasad Eye Institute, Hyderabad, India was done. Results: Forty‑two eyes of 42 patients were included in this study. The mean age at presentation was 48.52 ± 14.10 years (range: 12-70). Surgery was the major risk factor seen in 24 eyes (58.5%). Scleral infection was noted after vitreoretinal surgery (with scleral buckle) in 15 eyes, cataract surgery in 3 eyes, pterygium surgery in 3 eyes, corneoscleral tear repair and scleral buckle surgery in 3 eyes. Sixteen eyes (39%) were on systemic or topical steroids at the time of presentation. History of injury was noted in 9 eyes (22%) and diabetes mellitus in 7 patients (17%). Associated keratitis was noted in 9 eyes (21.4%). The scleral abscess was unifocal in 33 eyes (78.5%), multifocal in 6 eyes (14.2%) and diffuse in 3 eyes (7.14%). The final follow‑up ranged from 24 days to 37 months. The final visual acuity was better in 18 eyes (42.8%), stable in 13 (30.9%), and deteriorated in 7 eyes (16.6%). Recurrence was seen in 4 eyes (9.5%). Conclusions: Surgery is a major risk factor for infectious scleritis in our series. Fungus was the most common organism isolated. Thorough debridement and intensive use of medications have improved the outcome.

Website: www.meajo.org DOI: 10.4103/0974-9233.150634 Quick Response Code:

Key words: Bacterial, Fungal, Debridement, Infectious Scleritis, Outcomes, Risk Factors

INTRODUCTION

I

nflammation of the sclera (scleritis) can be idiopathic or a manifestation of systemic immune‑mediated disease, or less commonly due to infection. Prevalence of infectious scleritis varies between studies, ranging from 4.6%1 to 18%.2 Infectious scleritis can occur by secondary spread from an adjacent keratitis,3 severe infectious endophthalmitis,3 or primary scleral infection. Predisposing factors include systemic infection,1,4 systemic diseases,5 trauma,6 use of corticosteroid preparations,6 use of immunomodulators,7 previous scleritis8

or previous ocular surgery. Infectious scleritis was commonly reported after pterygium surgery associated with ocular irradiation or use of antimetabolites.9 Other surgeries include cataract,10 strabismus,11 glaucoma filtration surgery,12 suture removal,2 and vitreo‑retinal procedures.13 Pseudomonas aeruginosa was the most commonly reported organism.14 Other organisms include Staphylococcus species,2,5 Streptococcus species,15 hemophilus influenza,8 Stenotrophomonas maltophilia,16 Serratia marcescens,7 Mycobacterium species,17 Nocardia,6 fungus,6,14 and virus.18 Diagnosis and management of infectious scleritis remain a challenge. Diagnosis is often masked by the close resemblance

Departments of Cornea, Anterior Segment and Refractive Surgery Services, 1Jhaveri Microbiology Centre, 2L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Andhra Pradesh, India Corresponding Author: Dr. Somasheila I. Murthy, Department of Uveitis, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, L. V. Prasad Marg, Banjara Hills, Hyderabad ‑ 500 034, Andhra Pradesh, India. E‑mail: [email protected]

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to immune‑mediated scleritis clinically and therefore, there is often delay in the diagnosis. In suspected cases, microbiological evaluation of specimens obtained by scleral scraping in eyes with ulcerated lesions should be performed. Various modalities of treatment have been tried with variable success rates, which include topical medications alone,6 topical combined with systemic medications,19 antibiotic lavage,20 cryotherapy,21 amniotic membrane grafting,22 corneoscleral graft3 and finally enucleation or evisceration in nonreponsive or severe cases.3,23 The outcomes reported in the existing literature show varied clinical outcomes probably due to nonuniform clinical approach and practice.6,7,14,24 Based on existing literature and our clinical experience we adopted to debridement (diagnostic and therapeutic) with intensive medications in all the cases, which led to overall good visual and complete anatomical outcomes. To the best of our knowledge, this is the largest series of bacterial and fungal scleritis showing good anatomical and functional outcomes. We hereby report a series of 42 patients with bacterial and fungal scleritis with various risk factors, microbiological profile, and clinical outcomes.

Necrotic tissue was excised and collected for smear and cultures. The base and edges of the lesions were scraped for microbiology. Bare sclera was left exposed to aid penetration of postoperative antibiotics.

MATERIALS AND METHODS

Treatment Immediate treatment for all the eyes was based on smear report. If bacteria were noted in smears and also in smear‑negative case, broad spectrum antibiotics (fortified cefazolin 5% and ciprofloxacin 0.03% eye drops) were administered starting half‑hourly. Oral ciprofloxacin 500-750 mg twice a day was also administered. The treatment was further modified based on the culture and sensitivity report, obtained 24-72 h later. In cases of identification of fungal filaments on smears, 5% natamycin was commenced every half‑hourly along with oral ketoconazole (200 mg twice a day). Clinically resolution was defined as when the patient complained of no symptoms, and any sign of scleral inflammation disappeared on slit‑lamp examination.

We reviewed the medical records of all consecutive patients with microbiologically proven infectious scleritis presenting to the Cornea and Anterior Segment Service at the L. V. Prasad Eye Institute, India from March 2005 to December 2009. The study was approved by the Institutional Review Board of L. V. Prasad Eye Institute, Hyderabad, India, and was conducted in adherence to the tenets of the declaration of Helsinki. A total of 42 eyes of 42 patients were included in the study. All the eyes where the clinician strongly suspected infection underwent scleral deroofing of nodular lesions or debridement with exploration in ulcerated lesions. Procedure

Surgical steps: After peribulbar anesthesia, Nodular lesions Conjunctiva around the nodule was incised circumferentially to expose the underlying scleral lesion. An incision was made using no. 15 surgical blade on a  Bard Parker handle (Aspen Surgical™ Products, Caledonia, MI) and the nodule was deroofed. Ulcerated lesions Conjunctiva around the nodule was incised circumferentially to expose the lesion. Debridement was done using a no. 15 surgical blade on a Bard Parker handle. In both the scenarios, the wound was explored until clinically normal sclera was seen, and thorough debridement was done until the underlying uveal tissue was just barely visible with taking care not to perforate the globe. 204

Microbiology The samples were inoculated directly onto blood agar, chocolate agar, nonnutrient agar with Escherichia coli overlay, Sabouraud dextrose agar, potato dextrose agar, thioglycollate broth, and brain heart infusion broth. In eyes of scleritis associated with scleral buckle infection, the buckle and surrounding necrotic material were also inoculated in culture media. In all the eyes, a thorough exploration was done on the table to rule out the presence of multifocal lesions. Surgical debridement was repeated in eyes if there was, (1) Development of new scleral abscess or (2) No microbiological diagnosis established in previous attempt or (3) Nssssso clinical response in spite of use of sensitive antibiotics.

Information including patient’s age, risk factors, onset and course of the disease, pathogenic organism, methods of diagnosis, treatment, and outcomes were recorded. In the case of negative smear and cultures and no clinical improvement even at 48 h, the patient underwent repeat scleral scrapings for microbiology.

RESULTS During the study period, 235 patients presented with scleritis, of which 42 patients were diagnosed to have an infection (17.87%). Demographic characteristics [Table 1]: Forty‑two eyes of 42 patients (34 males and 8 females) were included in the study. The mean age at presentation was 48.52 ± 14.10 years (range: 12-70). Right eye was involved in 23 eyes and left eye in 19 eyes. The final follow‑up ranged from 24 days to 37 months. Three patients were lost to follow‑up, 2 patients before there was complete resolution of the primary infection and one patient after recurrence.

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Pterygium excision (2 years)

Systemic prednisolone and azathioprine Vegetative (wooden) matter injury, topical and systemic steroids FB (unknown) injury, topical and systemic steroids Systemic steroids

65/female

46/male

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Topical steroids

Topical and systemic steroids

VR surgery for RD (1‑month)

VR surgery for RD (6 months)

Systemic steroids

Corneal tear repair and VR surgery (3 years) VR surgery (15 years) Corneal tear repair and VR surgery (15 years)

30/male

62/male

35/male

59/male

52/female

41/female

35/male

66/male

Vegetative (wooden) matter injury

45/male

60/male

70/male

55/male

Risk factor (latent period)

Age/ gender

30

45

20

20

30

12

20

20

20

6

13

20

90

60

Duration of sym ptoms (days)

PL negative PL+PR accurate

20/120

20/30

CF 1 meter

20/200

20/80

20/20

20/20

20/40

20/60

20/120

20/20

20/25

Initia BCVA

Negative/ Staphylococcus species Negative/ Staphylococcus epidermidis

Negative/ Staphylococcus aureus

Negative/ Staphylococcus aureus

Negative/Aspergillus tereus

Negative/unidentified Dematacious fungi

Fungus/Paecelomyces lilacinus

Fungus/Dematacious fungus

Negative/Aspergillus flavus

Fungus/Aspergillus flavus

Fungus/negative

Fungus/negative

Negative/Colletotrichum dematium

Fungus/ cladosporium Sp

Microbiology smear/ culture

Table 1: Clinic characteristics, management and outcomes all the patients

Topical fortified cephazolin

Topical ofloxacin

Topical natamycin and itraconozole Systemic ketoconozole Topical natamycin Systemic ketoconozole Topical natamycin Systemic ketoconozole Topical fortified cephazolin and systemic ciprofloxacin Topical fortified cephazolin

Topical natamycin Systemic ketoconozole Topical natamycin Systemic ketoconozole Topical natamycin Systemic ketoconozole Topical natamycin Systemic ketoconozole

Topical natamycin Systemic ketoconozole Topical natamycin Systemic ketoconozole

Topical natamycin and itraconozole Systemic ketoconozole

Medical treatment

Buckle explantation Debridement Buckle explantation Debridement

Buckle explantation Debridement

Debridement once

Buckle explantation

Buckle explantation

Debridement 4 times 3 diagnostic, 1 therapeutic Debridement 4 times 1 diagnostic 3 therapeutic

Debridement 4 times 4 diagnostic

Debridement twice diagnostic

Debridement twice 2 diagnostic

Debridement thrice 3 diagnostic

Debridement thrice, 1 diagnostic, 2 therapeutic amphoterecin B wash once Debridement 1 diagnostic

Surgical treatment

36 days

30 days

15 days

30 days

30 days

20 days

90 days

77 days

60 days

28 days

60 days

40 days

90 days

12 months

Duration of treatment

Nil

Nil

Nil

Nil

Nil

Nil

Twice

Yes but with Brevibacterium Sp Nil

Nil

Nil

Nil

Nil

Thrice

Recurrence

PL negative PL+PR accurate

PL+PR accurate

20/20

CF 3 meters

CF 3 meters

20/40

20/20

20/20

20/40

20/100

20/25

20/25

20/25

Final BCVA

contd...

Phthisical eye Resolved

Resolved

Resolved

Resolved

Resolved

Resolved, cataract

Resolved

Resolved

Lost follow‑up

Resolved, cataract

Resolved

Resolved

Resolved

Outcome

Reddy, et al.: Bacterial and Fungal Scleritis

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206

Topical dexamethasone, DM Injury with vegetative (wooden) matter, DM PPV EL (24 days) s/p CSTR

65/male

47/male

52/male

63/male

50/male

Injury with vegetative (wooden) matter

VR surgery (10 years) VR surgery (2 years) Cataract surgery (12 days)

25/male

42/male

Injury with FB (unknown)

VR surgery (19 years) VR surgery (16 years) VR surgery (4 years) ?endophthalmitis s/p cataract surgery, vitreous biopsy negative Injury with vegetative matter (wooden), topical steroids Topical prednisolone , DM

38/male

55/female

47/male

67/female

30/male

41/male

59/male

Table 1: contd... Age/ Risk factor gender (latent period)

PL+PR accurate 20/80

60

20/160

20/20

CF 1 meter

20/125

20/100

CFCF

10

30

16

7

2

90

15

20/400

20/125

20

10

PL+PR accurate

20/200

PL+PR accurate 20/100

Initia BCVA

5

2

30

45

Duration of sym ptoms (days)

Actinomycetes/ Nocardia asteroides

Actinomycetes/ Nocardia asteroides

Negative/Nocardia asteroides

Actinomycetes/ Nocardia asteroides

Negative/Pseudomonas aeruginosa Negative/Pseudomonas aeruginosa GNB*/negative

GNB/Pseudomonas aeruginosa

GNB/Pseudomonas aeruginosa

Negative/Pseudomonas aeruginosa

Negative/ Staphylococcus aureus Negative/ Staphylococcus aureus Negative/ Staphylococcus aureus Negative/Pseudomonas aeruginosa

Microbiology smear/ culture

Topical and systemic amikacin

Topical and systemic amikacin

Topical and systemic amikacin

Topical fortified amikacin

Topical and systemic ciprofloxacin Topical prednisonone Topical and systemic ciprofloxacin Topical and systemic ciprofloxacin Topical and systemic ciprofloxacin

Topical and systemic ciprofloxacin

Topical and systemic ciprofloxacin

Topical fortified cephazolin Topical fortified cephazolin Topical fortified cephazolin Topical fortified ceftazidime and systemic ceftazidime

Medical treatment

Debridement four times

Debridement once

Debridement twice

Buckle explantation, debridement Buckle explantation, debridement Debridement intracameral ceftazidime and vancomycin Debridement once

Debridement once



Debridement once Multilayered AMG

Buckle explantation Debridement Buckle explantation Debridement Buckle explantation Debridement Debridement twice 1 diagnostic 1 therapeutic

Surgical treatment

60 days

71 days

60 days

50 days

36 days

20 days

30 days

21 days

45 days

90 days

80 days

30 days

33 days

32 days

Duration of treatment

Nil

Yes

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Recurrence

20/40

CF 1 meter

20/60

20/30

20/30

20/100

20/160

CF 1 meter

PL+PR accurate

20/200

20/25

20/100

PL+PR accurate 20/50

Final BCVA

contd...

Recurrance lost follow‑up Resolved

Resolved Cataract

Resolved

Resolved

Resolved

Resolved corneal scar Resolved Corneal scar Resolved

Resolved PED

Resolved

Resolved

Resolved

Resolved

Outcome

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VR surgery‑2 years

VR surgery‑8 years

VR surgery‑6 years

Pterygium excision with MMC‑23 days

VR surgery‑2 years

VR surgery‑7 years

22/male

12/male

53/female

39/male

52/male

45/male

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10

5

90

2

14

180

30

3

7

14

25

30

30

Duration of sym ptoms (days)

PL+PR accurate

PL+PR accurate

20/60

PL+PR accurate

No PL

CFCF

PL+PR accurate

PL+PR accurate No PL

20/60

20/40

20/60

PL+PR accurate

20/30

Initia BCVA

Negative/ Mycobacterium chelonae Negative/ Mycobacterium chelonae Negative/ Staphylococcus epidermidis, Mycobacterium chelonae Negative/ Corynebacterium diphtheriae Negative/ Corynebacterium diphtheriae Negative/ Brevibacterium

Negative/Beta Hemolytic Streptococci Acid‑fast bacilli/ Mycobacterium chelonae Negative/ Mycobacterium chelonae

Negative/Beta Hemolytic Streptococci GPC/Streptococcus anginosus

Negative/Streptococcus pneumonia

Negative/Nocardia asteroides Actinomycetes/ Nocardia asteroides

Microbiology smear/ culture

Topical fortified cephazolin

Topical ciprofloxacin

Topical ciprofloxacin and betamethasone

Topical fortified cephazolin Topical fortified amikacin Topical fortified amikacin and systemic azithromycin Topical fortified amikacin Topical fortified amikacin Topical ciprofloxacin

Topical fortified cephazolin, systemic ciprofloxacin Topical fortified cephazolin Topical fortified cephazolin

Topical and systemic amikacin Topical and systemic amikacin

Medical treatment

Buckle explantation

Debridement+ multilayered AMG+CAG Buckle explantation

Buckle explantation

Buckle explantation

Buckle explantation

Debridement twice

Debridement once

Buckle explantation

Debridement+FB removal+TA+BCL

Debridement once

Debridement once

Buckle explantation debridement

Debridement twice

Surgical treatment

15 days

30 days

40 days

30 days

30 days

30 days

28 days

24 days

16 days

17 days

30 days

50 days

30 days

13 days

Duration of treatment

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Recurrence

20/200

20/100

20/20

PL+PR inaccurate

PL+PR accurate No PL

PL+PR inaccurate

PL+PR inaccurate No PL

20/30

20/30

20/40

PL+PR accurate

20/40

Final BCVA

Resolved

Resolved

Resolved

Resolved

Resolved

Resolved

Resolved Phthisical Lost follow‑up Resolved Secondary glaucoma

Resolved

Resolved

Resolved

Resolved

Resolved

Outcome

BCVA: Best corrected visual acuity, CF: Counting fingers, CFCF: Counting fingers close to face, VR surgery: Vitreo‑retinal surgery, PL: Perception of light, PR: Projection of rays, AMG: Amniotic membrane grafting, PED: Persisting epithelial defect, *GNB: Gram negative bacilli, DM: Diabetes mellitus, PPV: Pars plana vitrectomy, EL: Endolaser, TA: Tissue adhesive, BCL: Bandage contact lens, FB: Foreign body, RD: Retinal detachment, CSTR: Committee on Solar‑Terrestrial Research, MMC: Mitomycin C, GPC: Gram‑positive cocci, CAG: Conjunctival autografting

48/male

Topical steroids, DM None

Injury with FB (metallic) VR surgery (30 days), DM, topical and systemic steroids Cataract surgery‑25 days, topical steroids Pterygium excision‑14 days Injury with vegetative (wooden) matter VR surgery‑30 days

50/male

12/male

30/male

64/male

70/female

59/male

51/male

Table 1: contd... Age/ Risk factor gender (latent period)

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Risk factors

The risk factors noted were previous surgery, use of topical and systemic steroids, injury and systemic illness like diabetes mellitus [Table 2]. Surgery was the major risk factor seen in 24 eyes (58.5%). All of these were referred cases, and the surgeries were performed in other institutes and hence the details were not available in the medical records. Forty percent of the patients with fungal scleritis were on either topical or systemic steroids or both at presentation. Eighty‑five percent of patients with Staphylococcus species, 60% of patients with Streptococcus species and 40% of patients with Pseudomonas scleritis had surgery as the predisposing factor for the development of scleritis. Trauma was the predisposing factor in 50% of patients with Nocardia scleritis. Clinical characteristics

The mean duration of symptoms before presentation was 31.79 ± 34.52 days (range: 2-180). The mean duration of the presentation was longer (54 days) after developing symptoms in patients with fungal scleritis compared with other organisms. Keratitis was noted in 9 eyes (21.42%). Scleral abscess was unifocal in 33 eyes (78.57%), multifocal in 6 eyes (14.28%) and diffuse in 3 eyes (7.14%). Microbiological profile, management and clinical outcomes

Fungus Fungus was the etiological agent in 10 eyes (23.8%) in our series. Nine of 10 had risk factors which included surgery in 3 eyes, injury in 3 and use of topical corticosteroids in 6 eyes at the time of presentation. All were treated with topical 5% natamycin and systemic ketoconazole. Topical itraconazole was added in eyes with recurrence (3 eyes). Amphotericin B (0.015%) wash was done in one eye at the time of therapeutic debridement. Multiple debridements were required in fungal scleritis for debulking the infection and also to improve penetration of medications. Mean duration of treatment was 92 days (range: 20 days to 1‑year). After initial resolution, two eyes presented with recurrence of fungal scleritis. One patient that was lost to follow‑up before complete resolution, [Figure 1]. Bacterial • Staphylococcus species was isolated in 7 eyes (16.6%). Staphylococcus aureus was seen in 5 eyes, Staphylococcus epidermidis in one eye and species was not identified in one eye. Mean duration of treatment was 29.43 ± 6.73 days (range: 15-36). Complete resolution was noted in all. One eye that had no perception of light at presentation became phthisical • Pseudomonas aeruginosa was the cause of scleritis in 6 eyes (14.2%). Predisposing factor was surger y in 3 eyes (scleral buckling ‑ 2 eyes, cataract surgery ‑ 1 eye) and trauma in 2 eyes. One patient (patient‑18) presented with postcataract surgery suspected endophthalmitis for 208

Table 2: Risk factors associated with bacterial and fungal scleritis Risk factor

Number (%)‑Latency between surgery and onset of symptoms (%)

Surgery

24 cases (58.5) 15‑VR surgery for RD (1‑month to 19 years) 3‑cataract surgery (5-25 days) 3‑pterygium surgery (14 days to 2 years) 3‑corneo‑scleral tear repair+PPV/SB (24 days to 15 years) 16 cases (39) 9 cases (22) 6‑vegetative matter 1‑metaliic FB 2‑unknown FB 7 cases (17)

Steroid Trauma

Diabetes mellitus

VR: Vitreo‑retinal, RD: Retinal detachment, PPV: Pars plana vitrectomy, SB: Scleral buckle, FB: Foreign body

which he underwent pars plana vitrectomy and vitreous biopsy, which did not yield any organism. One month later the patient developed scleral abscess at the site of cataract surgery incision, which was debrided and treated with topical and systemic ceftazidime, which was the only drug for which the organism was sensitive. In the other 5 cases, the organism was sensitive to ciprofloxacin and showed complete resolution with topical and systemic ciprofloxacin. Topical steroids were used in two eyes along with the antibiotics. Mean duration of treatment was 47.67 ± 30.44 days (range: 20-90). One eye underwent multilayered amniotic grafting for persistent epithelial defect. Poor visual acuity was seen in 2 eyes due to corneal scar [Figure 2] • Nocardia asteroids were the etiological agent in 6 eyes (14.2%). Three eyes were on topical or systemic steroids at presentation. All eyes were treated with topical amikacin 2.5%, five eyes were treated with systemic amikacin for a period of 7-14 days depending on the response. Mean duration of treatment was 47.33 ± 21.76 days (range: 13-71). Surgical debridement was done 1-4 times depending on the response. Complete resolution of infection was seen in 5 eyes. Recurrence was seen in one eye that subsequently was lost to follow‑up • Mycobacterium chelonae was isolated in 5 eyes (11.90%). The patients were treated with either only topical amikacin (3 eyes) or combined topical and systemic amikacin (1 eye). All the eyes were sensitive to amikacin. Complete resolution was seen in 3 eyes, and one patient was lost to follow‑up. One eye developed secondary glaucoma that was subsequently controlled by topical and systemic antiglaucoma medications. One patient had a mixed infection with S. epidermidis, which could be a contaminant • Streptococcus species was isolated in 4 eyes (9.52%). The eye with history of injury underwent foreign body removal

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a

b

a

b

c

d

c

d

Figure 1: Clinical photograph of right eye of a patient with pus point at 3O’clock position which revealed fungal etiology on scleral deroofing (a), at 3 weeks after scleral de-roofing and intensive antifungal medications (b), histopathology specimen of the scleral tissue stained with Gomori’s methanamine silver showing fungal filaments (c, white stars depicting fungal filaments), clinical photograph with a well epithelized surface, senile cataract and no evidence of infection (d)

and application of tissue adhesive due to perforation at the limbus. Resolution of scleritis was seen in all the eyes with duration of treatment ranging from 16 to 50 days. One eye that presented with visual acuity of only accurate projection of rays after sclera buckling surgery had become phthisical • Corynebacterium diphtheriae was isolated in 2 eyes (4.76%). One patient underwent debridement, multilayered amniotic membrane transplantation and conjunctival autografting. Complete resolution was seen in 40 days in one patient and 30 days in the other • Brevibacterium species was isolated in one patient on examination buckle was exposed with adjoining scleral necrosis. Scleritis was successfully treated with buckle explantation, debridement and topical cephazolin (sensitive) eye drops for 15 days. Visual outcomes

There was improvement in best spectacle‑corrected visual acuity in 18 eyes (42.85%), visual acuity was unchanged in 13 eyes (30.9%), and deteriorated in 7 eyes (16.66%). At final follow‑up 20/40 or better visual acuity was seen in 17 eyes (40.5%) and 20/50-20/200 in 9 eyes (21.5%) and worse than 20/200 in 16 eyes (38%), 14 of these 16 eyes had visual acuity of worse than 20/200 at presentation itself. Complications

Recurrence was seen in 4 eyes (9.52%), of which 3 were seen in patients with resolved fungal scleritis. In 2 of these eyes recurrence was with the same organism but in one eye it was due to Brevibacterium species, which was treated successfully. Other complications included cataract in 3 eyes, secondary glaucoma in one and persistent epithelial defect in one eye.

Figure 2: Clinical photograph of the left eye of a patient showing Pseudomonas aeuroginosa corneal infiltrate and scleral abscess (a), at 1-week of scleral deroofing showing uveal show and a resolving corneal infiltrate (b), histopathology specimen of scleral tissue after H and E stain showing inflammatory cells and Gram-negative bacilli (c), clinical photograph of the patient with well epithelised surface, scleral thinning with uveal show, corneal scar is also seen (d). There is no evidence of infection

DISCUSSION The proportion of infectious scleritis (17.87%) in our study is a little higher than previous reports.6 In this series, majority of the cases had predisposing factors such as surgery, trauma and corticosteroid use. Surgery is said to be most common predisposing factor for infectious scleritis, which was also noted in the present series (58.5%). vitreoretinal surgery (43%, 18/42) was the major predisposing factor followed by cataract (7%, 3/42) and pterygium (7%, 3/42). Infectious scleritis had been reported either after vitrectomy or scleral buckling surgery.24,25 In the scleral buckle infections, the patients, usually, present with chronic irritation and discomfort. The buckle is often colonized by microorganisms with minimal scleral necrosis. However in the present series, all patients had scleral necrosis extending beyond the scleral buckle which resolved after buckle explantation, debridement and appropriate antimicrobials, and therefore is not simple colonization. Smiddy et al.26 have shown that Staphylococcus species accounted for most of the culture positive buckle infections and hypothesized that biofilm enveloping the exoplanet hinders the penetration of antibiotics and effectively sequestrating a reservoir of potential pathogenic microbes. Though fungal scleritis is less common in western literature,27 it is the most common cause of scleritis in tropical countries like India.6 Incidence of fungal scleritis varied between different studies, 3-38%.6,28 Of all the fungi, scleritis is commonly reported with Aspergillus, other fungi include Metarrhizium anisopliae, Paecilomyces lilacinus, Scedosporium, Cephalosporium, Penicillium, Cladosporium, Candida parapsilosis, Petriellidium boydii, Fusarium and

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Rhizopus Acremonium.6,29‑31 We also report Colletotrichum dematium and Aspergillus tereus that have not been reported so far as a cause of infectious scleritis. Treating fungal scleritis is challenging due to the difficulty of diagnosis, the difficulty of drug penetration due to avascular nature of sclera and the limited number of antifungal agents. Existing literature does not provide any consensus on the class of antifungal or the route of administration to be followed. Moriarty et al.9 reported fungal hyphae in enucleated specimens from two patients in spite of aggressive topical and systemic antifungal therapy for 3 and 6 months, respectively. Surgical debridement helps debulk the infected deep stromal layers and also promotes penetration of antimicrobial agents into the affected tissue. It was hypothesized that recurring scleral abscesses are due to an immunologic response to fungal cell death but we have seen three recurrences in our series which were culture positive. Previous literature has shown poor outcome of fungal scleritis6,14,29 In our case series of 10, nine cases were successfully treated with aggressive debridement both as diagnostic and therapeutic modality and prolonged topical and systemic antifungals. Thorough debridement helps in debulking the organism thus dislodging the nidus and also increasing the drug penetration. In our series, patients with fungal sceritis required multiple debridements. Pseudomonas is the most common and fulminant organism causing infectious scleritis in the western literature.27 Due to poor success rate with medical therapy alone, clinicians resorted to other modalities such as subpalpebral irrigation with antibiotics, carbon dioxide laser, conjunctival recession and cryotherapy with variable success rates.3,32 In our series complete resolution was seen in all the six cases with surgical debridement, topical and systemic antibiotics. Topical steroids along with antibiotics were used in two cases. Role of corticosteroids has been controversial in infectious scleritis. Pseudomonas is known to exacerbate the issue destruction by upregulating multiple host cytokines and chemokines thus leading to worsening or recurrence by decreasing the ocular defense mechanism and increase the lytic enzyme activity.19,33 Along with appropriate antibiotics steroids help in decreasing the proteolytic enzymes by the microorganisms, polymorphonuclear leucocytes, corneal epithelial cells and keratocytes.34 Huang et al.35 and Ma et al.22 have successfully treated 3 and 4 cases respectively using low‑dose oral corticosteroids and postulated that low dose oral steroids eliminates the direct contact effect of topical steroids and reduces the likelihood of exacerbation or late recurrence of scleritis. A delicate balance exists between the induction of a protective and a destructive response to ocular infection. Steroids must be used only under close observation as while tissue destruction is reduced, host immune response to the infection will also be suppressed.36 210

Apart from routine microbiological evaluation specific emphasis should be laid in the diagnosis and management of fastidious organisms like nocardia. In our series, all the 6 cases were sensitive to amikacin. Though trimethoprim‑sulfamethoxazole and amikacin are effective drugs in the management of nocardia scleritis, topical and systemic amikacin with thorough debridement may be the treatment of choice in the successful management of nocardia scleritis. Brevibacterium species are gram‑positive rods present in dairy products and human skin. It is a rare cause of ocular infection. Ghosheh et al. have reported a case of keratitis with Brevibacterium casei in a patient with aerosolized crack cocaine Use which showed complete resolution with sensitive antibiotics.37 Till date there are no cases of infectious scleritis due to Brevibacterium reported. We have seen two cases in our series. One case had scleral buckling as a risk factor, and the other case was primarily fungal scleritis, which was successfully treated with topical and systemic antifungal medications for 60 days. Twenty‑two days after cessation of antifungals patient presented with recurrence, but on debridement and subsequent culture showed Brevibacterium species. Both cases were successfully treated with topical cefazolin and oral ciprofloxacin was used in one case. Based on the outcomes reported in the existing literature and experience of treating previous cases we adopted to debridement with intensive medications in all the cases which have led to overall good visual and complete anatomical outcomes. Useful vision (better than 20/200) was seen in 26 cases (61.09%). Most of the cases with poor visual acuity were due to previous vitreo‑retinal surgery, corneal scar or cataract. None of the eyes in this series required either enucleation or evisceration. This data may not be representative of the prevalence of bacterial and fungal scleritis because this was a retrospective study from a tertiary eye care hospital.

CONCLUSIONS Bacterial and fungal scleritis is associated with a predisposing factor in the majority of cases. Pterygium surgery is the most common predisposing factor in western countries that may not be true always in our scenario. Fungi were the most common organism seen in our series, but outcome was good, contrary to poor results demonstrated in previous series. Thorough debridement, which may have to be repeated, can be both diagnostic and therapeutic, leaving bare sclera for penetration of antibiotics; and the intensive use of antimicrobials helped in eliminating the microbes and thus improving final outcome.

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Middle East African Journal of Ophthalmology, Volume 22, Number 2, April - June 2015

Cite this article as: Reddy JC, Murthy SI, Reddy AK, Garg P. Risk factors and clinical outcomes of bacterial and fungal scleritis at a tertiary eye care hospital. Middle East Afr J Ophthalmol 2015;22:203-11. Source of Support: Nil, Conflict of Interest: None declared.

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Risk factors and clinical outcomes of bacterial and fungal scleritis at a tertiary eye care hospital.

The aim was to analyze demographics, risk factors, pathogenic organisms, and clinical outcome in cases with microbiologically proven bacterial or fung...
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