Necrotizing nocardial scleritis after combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation: a case report and review of the literature

Abstract

We report the history and clinical presentation of an 88-year-old female with Fuchs dystrophy who developed an acute anterior necrotizing scleritis in her left eye 23 months after an uncomplicated combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation which progressed to slceral perforation with uveal prolapses. The patient underwent a complete systemic work-up for both autoimmune and infectious causes of scleritis. Surgical specimens of the area of scleral perforation were sent for histology and microbiologic studies. Analysis of surgical specimens revealed the presence of culture-proven Nocardia asteroides as a causative agent for the patient's scleral perforation. Results of her systemic autoimmune work-up were not conclusive. Successful treatment with tectonic scleral reinforcement with donor corneal tissue and preserved pericardium, oral and topical trimethoprim-sulfamethoxazole and topical amikacin salvaged the globe and increased vision. The patient's final best-corrected visual acuity sixteen months after her last operation remains 20/70. Prompt surgical intervention with submission of appropriate specimens for pathological diagnosis and microbiology, along with consultation with rheumatologic and infectious disease specialists, are mandatory to minimize visual loss in cases of suspected infectious necrotizing scleritis.

Contact Lens-associated Nocardial Necrotizing Scleritis

“…Similar to the favorable responses using Bactrim reported by Ramos-Esteban et al [5], Seth and Gaudio [10], and Choudhry et al [11], this case demonstrated clinical improvement within one week and resolution within six months after initiation of Bactrim. Amikacin and minocycline have been recommended in cases of nocardial infection resistant to oral Bactrim DS [12].…”

“…Some of the predisposing factors identified include cataract surgery, scleral buckle surgery, trauma with vegetable matter, and soft contact lens-related keratitis with extension to the sclera [5]. This paper describes a case of culture-proven Nocardial necrotizing scleritis in a contact lens-wearing patient without an associated keratitis.…”

Necrotizing Nocardial Scleritis Successfully Treated with Surgical Debridement and Topical Polyvinyl Alcohol Iodine and Antibiotics

“…The predisposing factors include steroid use, diabetes mellitus, combined penetrating keratoplasty and PEA with IOL implantation, sclera buckle surgery, trauma, and cataract surgery ( Table 2). [6][7][8][9][10][11][12][13] In our patient, prior cataract surgery and farm work were probably the cause of the infectious scleritis, but the exact cause was not determined.…”

Infectious Scleritis

“…4a, b). Although rare, Nocardia scleritis has been reported frequently in literature as isolated case reports [27][28][29][30][31][32][33][34][35][36][37][38][39]. Sahu et al [27] reported a series of three patients and reviewed the literature for this entity.…”

“…In the recent years, there has been an increase in the number of cases of ocular infection due to scleritis are mainly cataract surgery [1 • , 29], scleral buckling surgery [1 • , 31, 32], penetrating keratoplasty [33], subtenon triamcinolone acetonide injection for cystoid macular edema [34], trauma [35], and contact lens wear [36,37]. Nocardia asteroides was the most predominant organism followed by Nocardia nova [38].…”