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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

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Letters to The Journal

Fig. 2 (Brunette and Stulting). Gram stain of a scraping from the necrotic sclera disclosed thickwalled yeast forms (arrow) (x 400). paralimbal scierai nodule with secondary corneal infiltration that was thought to be sporotrichotic because of the nodular manifestation and the efficacy of potassium iodide therapy, but the diagnosis was never proven by culture. Secondary infiltration 2 or perforation 3 of the sclera has been described in association with intraocular sporotrichosis, but sclera is general­ ly resistant to sporotrichotic invasion. Often it is one of the last preserved structures in eyes otherwise extensively destroyed by necrotizing endophthalmitis caused by S. schenckii.4·0 Iodide therapy remains the treatment of choice in cutaneous and lymphocutaneous spo­ rotrichosis, as in infections of the eyelids and conjunctiva. A typical dose is 15 drops three times a day of a saturated solution of potassium iodide (usually 50 mg per drop), with gradual increases to 30 or 40 drops three times a day. Iodide therapy should be continued for at least one month after clinical recovery. Indigestion and iododermatitis are possible side effects. Amphotericin B appears to be superior to io­ dide therapy in extracutaneous and visceral infections and would be recommended in more severe intraocular and orbital infections, as well as in any ocular infection resistant to iodide therapy. All forms of the disease are poorly responsive to miconazole, flucytosine, and ketoconazole.

References 1. De Caralt, D.: Escleritis micósica. Arch. Oftalmol. Hisp. Am. 28:626, 1928.

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2. Font, R. L., and Jakobiec, F. A.: Granulomatous necrotizing retinochoroiditis caused by Sporotrichum schenkii. Report of a case including immunofluorescence and electron microscopical studies. Arch. Ophthalmol. 94:1513, 1976. 3. Legry, T., Sourdel, M., and Velter, E.: Sporotrichose gommeuse disséminée avec lésions oculaires (iridocyclite et gommes de l'iris) et spina ventosa sporotrichosique. Bull. Mem. Soc. Med. Hop. Paris 32:124, 1911. 4. Kurosawa, A., Pollock, S. C , Collins, M. P., Kraff, C. R., and Tso, M. O. M.: Sporothrix schenckii endophthalmitis in a patient with human immunode­ ficiency virus infection. Arch. Ophthalmol. 106:376, 1988. 5. Levy, J. H.: Intraocular sporotrichosis. Report of a case. Arch. Ophthalmol. 85:574, 1971.

Nocardial Scleritis James G. Brooks, Jr., M.D., Richard A. D. Mills, F.R.A.C.O., and Douglas J. Coster, F.R.A.C.O. Department of Ophthalmology, Flinders Medical Centre. Inquiries to D. J. Coster, Department of Ophthalmology, Flinders Medical Centre, Bedford Park, South Australia 5042. A 90-year-old woman underwent left extracapsular cataract extraction with anterior chamber intraocular lens implantation on Dec. 11, 1990. Chloramphenicol 0.5% and prednisolone phosphate 0.5% drops were instilled postoperatively. One week later, however, necrotic scleritis of the temporal perilimbal region was noted. Initial intensive therapy with topical and oral cephalexin was unsuccessful and the area was surgically debrided. Microbiologie studies disclosed no organisms. Because of con­ tinued inflammation, repeat scrapings were performed but again failed to isolate an organ­ ism. Oral administration of corticosteroids re­ sulted in a marked improvement in scierai in­ flammation, but attempts to taper the dosage resulted in recurrence of inflammation. On referral to our institution on Jan. 16,1991, the patient's medications included 75 mg of prednisone per day and topical dexamethasone, twice a day. Best-corrected visual acuity was 20/80 in the left eye, and slit-lamp examination showed a large area of temporal scierai thin­ ning with ischemie and necrotic borders (Fig. 1). Examination of scrapings demonstrated

Sporothrix schenckii scleritis.

370 AMERICAN JOURNAL OF OPHTHALMOLOGY September, 1992 known agricultural or other direct exposure to fungal elements. Infectious keratitis after ra...
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