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Paecilomyces: A New Fungus to Fear?
Poster Presentations
371
the first reported case of papilledema as the sole presenting sign of a Chiari I malformation without any neurological symptoms of increased intracranial pressure. Case Summary: A 39-year-old female presented for a routine ophthalmic exam. Her medical history was unremarkable. The patient was of average weight for height and denied headaches. Best-corrected visual acuities were 20/ 20 O.D., O.S. External examination, slit lamp examination, ocular motility, and pupil testing were normal. Dilated fundus exam revealed optic disc edema in both eyes. Bscan imaging and Humphrey visual field testing were within normal limits. Cirrus optical coherence tomography imaging confirmed optic disc edema. Magnetic resonance imaging revealed the source of papilledema to be Chiari I malformation of 9 mm tonsilar herniation. The patient was referred to a neurologist specializing in treating Chiari malformations. Conclusion: A case such as this can masquerade as pseudotumor cerebri (PTC), as these cases often present similarly. Some in the literature have questioned if these disorders are related and that the Chiari 1 malformation may be secondary to the PTC. Patients presenting with optic disc edema should have emergent advanced imaging to investigate the etiology, especially before a lumbar puncture is considered which may worsen the tonsilar herniation. Initial treatment for PTC involves weight loss and diuretics while treatment for symptomatic Chiari 1 malformation is surgical decompression.
epithelialization had completed with repeat corneal scrapings failing to produce Paecilomyces, indicating a resolution of the infection. The patient remained on oral voriconazole and topical anti-inflammatory medications. Conclusion: Treating a corneal infection is always a difficult process, with outcome being highly dependent on the timeliness of an appropriate treatment and underlying ability of the patient to fight infection. The patient in this report started inappropriate treatment with a corticosteroid/antibiotic combination and had a compromised immune system. Patients with known risk factors for fungal keratitis should be regarded as highly suspicious for fungal infection and treated aggressively with the guidance of laboratory results. Failure to respond to antibiotic treatment should increase suspicion of fungal infection, including rare fungi that are resistant to typical antimycotics, such as amphotericin-B and natamycin. Literature review and in this case, laboratory sensitivity testing, shows P. lilacinus to be such a microorganism. A 2010 report reviewing fungal keratitis cases at Wills Eye Hospital suggests that infection with Paecilomyces species may be on a significant increase.
Poster 58
Background: Laser-assisted in situ keratomileusis (LASIK) is 1 of the most common refractive procedures performed both in the United States and around the world, with reports ranging from 700,000 to 4,000,000 procedures annually. Complications for this procedure are well-known and have been described extensively. This case, we believe, exhibits the first report of an interesting idiopathic variation possibly related to the potential space caused by flap creation. Case Report: A 25-year-old male presented for a refractive evaluation approximately 5 years after having LASIK performed on both eyes without complication. Best-corrected visual acuities were 20/25+ O.D. and 20/20+ O.S. Slit lamp exam showed bilateral, whitish, sub-epithelial opacities–all at the same corneal depth–more numerous in the right eye than the left. Both anterior segment photographs and anterior segment optical coherence tomography (Cirrus optical coherence tomography [OCT]) images were obtained, confirming that the deposits were all of similar size, reflectivity, and corneal depth – clearly at the level of the flap interface. Two months later, a flap lift was performed to attempt to wash out the opacities and obtain a sample for lab testing. Though a sterile saline washout failed to remove any deposits, a sample was obtained and sent for lab testing. The results revealed no malignant cells/acellular debris only and were positive for calcium. Bloodwork was normal, though it is perhaps worth noting
Paecilomyces: A New Fungus to Fear? Seth Salley, O.D., Southern Eye Associates, Memphis, Tennessee Background: Paecilomyces is a fungus known to rarely cause corneal infection. We present a case of fungal keratitis in a patient with multiple risk factors that was treated successfully with a combination of medical and surgical methods. Case Summary: A 46-year-old white male with uncontrolled diabetes reported a painful red eye after removing a soft contact lens following overnight use. A non-eye care physician prescribed a topical corticosteroid/antibiotic to be used three times daily. Progressively decreasing vision and an external ‘‘white spot’’ prompted the patient to report to our clinic 10 days later. A large paracentral corneal ulcer was present. The corticosteroid/antibiotic was discontinued and aggressive fortified topical antibiotics were begun. Corneal scraping resulted in detection of fungal elements by gram stain. Topical natamycin and oral fluconazole were used until results of culturing revealed a microorganism sensitive to voriconazole. Topical and oral voriconazole were used until failure to control the spread of infection toward the sclera prompted a therapeutic penetrating keratoplasty. A culture from the corneal button revealed Paecilomyces lilacinus. As of the submission date, re-
Poster 59 Bilateral Idiopathic Corneal Calcium Deposits at LASIK Flap Interface Nathaniel Pelsor, O.D., Ocular Disease Resident, Bennett and Bloom Eye Centers, Louisville, Kentucky
371
the first reported case of papilledema as the sole presenting sign of a Chiari I malformation without any neurological symptoms of increased intracranial pressure. Case Summary: A 39-year-old female presented for a routine ophthalmic exam. Her medical history was unremarkable. The patient was of average weight for height and denied headaches. Best-corrected visual acuities were 20/ 20 O.D., O.S. External examination, slit lamp examination, ocular motility, and pupil testing were normal. Dilated fundus exam revealed optic disc edema in both eyes. Bscan imaging and Humphrey visual field testing were within normal limits. Cirrus optical coherence tomography imaging confirmed optic disc edema. Magnetic resonance imaging revealed the source of papilledema to be Chiari I malformation of 9 mm tonsilar herniation. The patient was referred to a neurologist specializing in treating Chiari malformations. Conclusion: A case such as this can masquerade as pseudotumor cerebri (PTC), as these cases often present similarly. Some in the literature have questioned if these disorders are related and that the Chiari 1 malformation may be secondary to the PTC. Patients presenting with optic disc edema should have emergent advanced imaging to investigate the etiology, especially before a lumbar puncture is considered which may worsen the tonsilar herniation. Initial treatment for PTC involves weight loss and diuretics while treatment for symptomatic Chiari 1 malformation is surgical decompression.
epithelialization had completed with repeat corneal scrapings failing to produce Paecilomyces, indicating a resolution of the infection. The patient remained on oral voriconazole and topical anti-inflammatory medications. Conclusion: Treating a corneal infection is always a difficult process, with outcome being highly dependent on the timeliness of an appropriate treatment and underlying ability of the patient to fight infection. The patient in this report started inappropriate treatment with a corticosteroid/antibiotic combination and had a compromised immune system. Patients with known risk factors for fungal keratitis should be regarded as highly suspicious for fungal infection and treated aggressively with the guidance of laboratory results. Failure to respond to antibiotic treatment should increase suspicion of fungal infection, including rare fungi that are resistant to typical antimycotics, such as amphotericin-B and natamycin. Literature review and in this case, laboratory sensitivity testing, shows P. lilacinus to be such a microorganism. A 2010 report reviewing fungal keratitis cases at Wills Eye Hospital suggests that infection with Paecilomyces species may be on a significant increase.
Poster 58
Background: Laser-assisted in situ keratomileusis (LASIK) is 1 of the most common refractive procedures performed both in the United States and around the world, with reports ranging from 700,000 to 4,000,000 procedures annually. Complications for this procedure are well-known and have been described extensively. This case, we believe, exhibits the first report of an interesting idiopathic variation possibly related to the potential space caused by flap creation. Case Report: A 25-year-old male presented for a refractive evaluation approximately 5 years after having LASIK performed on both eyes without complication. Best-corrected visual acuities were 20/25+ O.D. and 20/20+ O.S. Slit lamp exam showed bilateral, whitish, sub-epithelial opacities–all at the same corneal depth–more numerous in the right eye than the left. Both anterior segment photographs and anterior segment optical coherence tomography (Cirrus optical coherence tomography [OCT]) images were obtained, confirming that the deposits were all of similar size, reflectivity, and corneal depth – clearly at the level of the flap interface. Two months later, a flap lift was performed to attempt to wash out the opacities and obtain a sample for lab testing. Though a sterile saline washout failed to remove any deposits, a sample was obtained and sent for lab testing. The results revealed no malignant cells/acellular debris only and were positive for calcium. Bloodwork was normal, though it is perhaps worth noting
Paecilomyces: A New Fungus to Fear? Seth Salley, O.D., Southern Eye Associates, Memphis, Tennessee Background: Paecilomyces is a fungus known to rarely cause corneal infection. We present a case of fungal keratitis in a patient with multiple risk factors that was treated successfully with a combination of medical and surgical methods. Case Summary: A 46-year-old white male with uncontrolled diabetes reported a painful red eye after removing a soft contact lens following overnight use. A non-eye care physician prescribed a topical corticosteroid/antibiotic to be used three times daily. Progressively decreasing vision and an external ‘‘white spot’’ prompted the patient to report to our clinic 10 days later. A large paracentral corneal ulcer was present. The corticosteroid/antibiotic was discontinued and aggressive fortified topical antibiotics were begun. Corneal scraping resulted in detection of fungal elements by gram stain. Topical natamycin and oral fluconazole were used until results of culturing revealed a microorganism sensitive to voriconazole. Topical and oral voriconazole were used until failure to control the spread of infection toward the sclera prompted a therapeutic penetrating keratoplasty. A culture from the corneal button revealed Paecilomyces lilacinus. As of the submission date, re-
Poster 59 Bilateral Idiopathic Corneal Calcium Deposits at LASIK Flap Interface Nathaniel Pelsor, O.D., Ocular Disease Resident, Bennett and Bloom Eye Centers, Louisville, Kentucky