Letters to The Journal
Vol. 113, No. 6
Western blot analysis had been repeatedly per formed, seroconversion eventually occurred. Localized ocular infection seemed to have developed in this patient, although metastatic spread could not be excluded because a bron chial lavage was not performed. The differential diagnosis of a conjunctival granuloma in otherwise clinically healthy pa tients, therefore, should include not only sarcoidosis, tuberculosis, the presence of foreign bodies, and superficial mycotic infections; but also infection with opportunistic fungi and the possible existence of an undetected underlying infection with HIV. Ophthalmologists may have a key role in the early diagnosis of an opportunistic conjunctival infection by direct ing attention to an underlying immunocompromising disease. Excisional biopsy and histopathologic analysis are imperative in this setting.
References 1. Armstrong, D.: Problems in management of opportunistic fungal disease. Rev. Infect. Dis. 2:S1591, 1989. 2. Diamond, R. D.: Cryptococcus neoformans. In Mandell, G. L., Douglas, R. G., and Bennett, J. E. (eds.): Principles and Practice of Infectious Diseases, vol. 2. New York, John Wiley & Sons, 1979, pp. 2023-2034. 3. Pettit, J. H. S.: Cryptococcosis. In MansonBahr, P. E. C, and Bell, D. R.(eds.): Tropical Diseas es. London, Bailliere Tindall, 1987, pp. 714-717.
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creased vision in her right eye. She had been treated elsewhere with homatropine 5% with out improvement. Four weeks previously, pri mary varicella-zoster infection had been diag nosed. Examination disclosed a visual acuity of R.E.: 20/40 and L.E.: 20/20. There were many crust ed skin lesions on her cheeks and forehead. Her right preauricular and submandibular lymph nodes were enlarged. Her right globe was tend er to palpation. Corneal sensation and intraoc ular pressures were normal. Mild chemosis and marked conjunctival hyperemia were present. There was a diffuse zone of deep episcleral and scleral hyperemia nasally (Fig. 1). The corneal epithelium was intact and did not stain with rose bengal or fluorescein sodium solutions. There were scattered subepithelial opacities and a 1.75 x 1.75-mm zone of stromal edema with nonsuppurative fine inflammatory cell in filtration (Fig. 2). A few folds in Descemet's membrane were present. There were trace cells and flare in the anterior chamber. Varicella-zoster serum antibody titer taken five days after manifestation was 1:2,048. Seven months later repeat titer was 1:128, indicating recent varicella-zoster infection. Other causes of disciform keratitis were excluded. Conjuncti val cultures were negative for herpes simplex
Scleritis Associated With Varicellazoster Disciform Stromal Keratitis Anisa B. T h r e l k e l d , M.D., D e a n Eliott, M.D., and Terrence P. O'Brien, M.D. Wilmer Ophthalmological Institute. Inquiries to Terrence P. O'Brien, M.D., Ocular Microbi ology Laboratory, Wilmer Institute, Woods 255, Johns Hopkins Hospital, Baltimore, MD 23205. Stromal keratitis is infrequently associated with primary varicella-zoster virus infections.1"6 A 14-year-old black girl had a four-day histo ry of pain, epiphora, photophobia, and de
Fig. 1 (Threlkeld, Eliott, and O'Brien). Scleral hy peremia persists after topical instillation of 10% phenylephrine solution.
722
June, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
ation of scleritis is important as additional therapy may be indicated.
References
Fig. 2 (Threlkeld, Eliott, and O'Brien). Disciform stromal edema associated with varicella-zoster infec tion. virus and adenovirus. Serologic tests for syphi lis, herpes simplex virus, cytomegalovirus, Epstein-Barr virus, Lyme disease, and adenovirus were negative for recent infection. Measles, mumps, and rubella titers reflected her immu nization status. Cycloplegia and lubricants were continued. Because of persistent stromal edema and in flammation, mild uveitis, and decreased vision, prednisolone acetate 1%, topically four times a day, was added. Conjunctival, episcleral, and scleral hyperemia and edema decreased. Globe tenderness resolved. Persistent stromal and anterior chamber inflammation prompted an increase in corticosteroid frequency to six times per day. Within seven days, the subepithelial opacities, disciform stromal keratitis, and mild uveitis resolved with minimal residual stromal haze in the affected zone. Examination seven months later disclosed a visual acuity of R.E.: 20/20. The conjunctiva and sclera were normal. There was minimal, residual anterior stromal scarring. In our patient, serologic testing confirmed varicella-zoster infection. Wilhelmus, Hamill, and Jones 5 reported five cases and reviewed a total of 32 patients with varicella-zoster disci form stromal keratitis, none of whom had an associated scleritis. Similarities between our patient and those described by Wilhelmus, Hamill, and Jones 5 included the late onset of disciform stromal keratitis after varicella zoster infection and an apparent response to topical corticosteroid therapy. Awareness of the associ
1. Edwards, T.: Ophthalmic complications from varicella. J. Pediatr. Ophthalmol. 2:37, 1965. 2. Jordan, P. R., Noel, L. P., and Clarke, W. N.: Ocular involvement in varicella. Clin. Pediatr. 23:434, 1984. 3. Ostler, H. B., and Thygeson, P.: The ocular manifestations of herpes zoster, varicella, infectious mononucleosis and cytomegalovirus disease. Surv. Ophthalmol. 21:148, 1976. 4. Rosenbaum, H. D.: Varicella and the cornea. Am. J. Ophthalmol. 28:113, 1950. 5. Wilhelmus, K. R., Hamill, M. B., and Jones, D. B.: Varicella disciform stromal keratitis. Am. J. Ophthalmol. 111:575, 1991.
Suppurative Keratitis From Herbal Ocular Preparation T. J. Hufnagel, M.D., and O. D. S c h e i n , M.D. Wilmer Institute, Johns Hopkins University. Inquiries to Oliver D. Schein, M.D., 116 Wilmer Bldg., Johns Hopkins Hospital, Baltimore, MD 21205. The association of bacterial keratitis with microbial contamination of in-use ocular medi cations has recently been emphasized. 1,2 We encountered an unusual case of gram-negative suppurative bacterial keratitis secondary to the use of a nonpharmaceutical herbal eyedrop preparation. A 17-year-old girl monitored for herpes sim plex keratouveitis of the right eye and with a visual acuity of R.E.: 20/30, L.E.: 20/20 was seen in June 1991. The patient was asympto matic, and slit-lamp examination disclosed an intact corneal epithelium with a large central but stable disciform scar. While tapering treat ment with corticosteroid eyedrops (predniso lone acetate 1%), the patient was advised by a friend to substitute an herbal eyedrop. She abruptly ceased using the corticosteroid and initiated the use of the herbal eyedrops. After approximately two weeks, she had pain, red ness, and vision loss in her right eye. At initial
Vol. 113, No. 6
Western blot analysis had been repeatedly per formed, seroconversion eventually occurred. Localized ocular infection seemed to have developed in this patient, although metastatic spread could not be excluded because a bron chial lavage was not performed. The differential diagnosis of a conjunctival granuloma in otherwise clinically healthy pa tients, therefore, should include not only sarcoidosis, tuberculosis, the presence of foreign bodies, and superficial mycotic infections; but also infection with opportunistic fungi and the possible existence of an undetected underlying infection with HIV. Ophthalmologists may have a key role in the early diagnosis of an opportunistic conjunctival infection by direct ing attention to an underlying immunocompromising disease. Excisional biopsy and histopathologic analysis are imperative in this setting.
References 1. Armstrong, D.: Problems in management of opportunistic fungal disease. Rev. Infect. Dis. 2:S1591, 1989. 2. Diamond, R. D.: Cryptococcus neoformans. In Mandell, G. L., Douglas, R. G., and Bennett, J. E. (eds.): Principles and Practice of Infectious Diseases, vol. 2. New York, John Wiley & Sons, 1979, pp. 2023-2034. 3. Pettit, J. H. S.: Cryptococcosis. In MansonBahr, P. E. C, and Bell, D. R.(eds.): Tropical Diseas es. London, Bailliere Tindall, 1987, pp. 714-717.
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creased vision in her right eye. She had been treated elsewhere with homatropine 5% with out improvement. Four weeks previously, pri mary varicella-zoster infection had been diag nosed. Examination disclosed a visual acuity of R.E.: 20/40 and L.E.: 20/20. There were many crust ed skin lesions on her cheeks and forehead. Her right preauricular and submandibular lymph nodes were enlarged. Her right globe was tend er to palpation. Corneal sensation and intraoc ular pressures were normal. Mild chemosis and marked conjunctival hyperemia were present. There was a diffuse zone of deep episcleral and scleral hyperemia nasally (Fig. 1). The corneal epithelium was intact and did not stain with rose bengal or fluorescein sodium solutions. There were scattered subepithelial opacities and a 1.75 x 1.75-mm zone of stromal edema with nonsuppurative fine inflammatory cell in filtration (Fig. 2). A few folds in Descemet's membrane were present. There were trace cells and flare in the anterior chamber. Varicella-zoster serum antibody titer taken five days after manifestation was 1:2,048. Seven months later repeat titer was 1:128, indicating recent varicella-zoster infection. Other causes of disciform keratitis were excluded. Conjuncti val cultures were negative for herpes simplex
Scleritis Associated With Varicellazoster Disciform Stromal Keratitis Anisa B. T h r e l k e l d , M.D., D e a n Eliott, M.D., and Terrence P. O'Brien, M.D. Wilmer Ophthalmological Institute. Inquiries to Terrence P. O'Brien, M.D., Ocular Microbi ology Laboratory, Wilmer Institute, Woods 255, Johns Hopkins Hospital, Baltimore, MD 23205. Stromal keratitis is infrequently associated with primary varicella-zoster virus infections.1"6 A 14-year-old black girl had a four-day histo ry of pain, epiphora, photophobia, and de
Fig. 1 (Threlkeld, Eliott, and O'Brien). Scleral hy peremia persists after topical instillation of 10% phenylephrine solution.
722
June, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
ation of scleritis is important as additional therapy may be indicated.
References
Fig. 2 (Threlkeld, Eliott, and O'Brien). Disciform stromal edema associated with varicella-zoster infec tion. virus and adenovirus. Serologic tests for syphi lis, herpes simplex virus, cytomegalovirus, Epstein-Barr virus, Lyme disease, and adenovirus were negative for recent infection. Measles, mumps, and rubella titers reflected her immu nization status. Cycloplegia and lubricants were continued. Because of persistent stromal edema and in flammation, mild uveitis, and decreased vision, prednisolone acetate 1%, topically four times a day, was added. Conjunctival, episcleral, and scleral hyperemia and edema decreased. Globe tenderness resolved. Persistent stromal and anterior chamber inflammation prompted an increase in corticosteroid frequency to six times per day. Within seven days, the subepithelial opacities, disciform stromal keratitis, and mild uveitis resolved with minimal residual stromal haze in the affected zone. Examination seven months later disclosed a visual acuity of R.E.: 20/20. The conjunctiva and sclera were normal. There was minimal, residual anterior stromal scarring. In our patient, serologic testing confirmed varicella-zoster infection. Wilhelmus, Hamill, and Jones 5 reported five cases and reviewed a total of 32 patients with varicella-zoster disci form stromal keratitis, none of whom had an associated scleritis. Similarities between our patient and those described by Wilhelmus, Hamill, and Jones 5 included the late onset of disciform stromal keratitis after varicella zoster infection and an apparent response to topical corticosteroid therapy. Awareness of the associ
1. Edwards, T.: Ophthalmic complications from varicella. J. Pediatr. Ophthalmol. 2:37, 1965. 2. Jordan, P. R., Noel, L. P., and Clarke, W. N.: Ocular involvement in varicella. Clin. Pediatr. 23:434, 1984. 3. Ostler, H. B., and Thygeson, P.: The ocular manifestations of herpes zoster, varicella, infectious mononucleosis and cytomegalovirus disease. Surv. Ophthalmol. 21:148, 1976. 4. Rosenbaum, H. D.: Varicella and the cornea. Am. J. Ophthalmol. 28:113, 1950. 5. Wilhelmus, K. R., Hamill, M. B., and Jones, D. B.: Varicella disciform stromal keratitis. Am. J. Ophthalmol. 111:575, 1991.
Suppurative Keratitis From Herbal Ocular Preparation T. J. Hufnagel, M.D., and O. D. S c h e i n , M.D. Wilmer Institute, Johns Hopkins University. Inquiries to Oliver D. Schein, M.D., 116 Wilmer Bldg., Johns Hopkins Hospital, Baltimore, MD 21205. The association of bacterial keratitis with microbial contamination of in-use ocular medi cations has recently been emphasized. 1,2 We encountered an unusual case of gram-negative suppurative bacterial keratitis secondary to the use of a nonpharmaceutical herbal eyedrop preparation. A 17-year-old girl monitored for herpes sim plex keratouveitis of the right eye and with a visual acuity of R.E.: 20/30, L.E.: 20/20 was seen in June 1991. The patient was asympto matic, and slit-lamp examination disclosed an intact corneal epithelium with a large central but stable disciform scar. While tapering treat ment with corticosteroid eyedrops (predniso lone acetate 1%), the patient was advised by a friend to substitute an herbal eyedrop. She abruptly ceased using the corticosteroid and initiated the use of the herbal eyedrops. After approximately two weeks, she had pain, red ness, and vision loss in her right eye. At initial
