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Corynebacterium Scleritis
Vol. 117, No. 3
Letters to The Journal
405
2. Norusis, M. J.: SPSS/PC+ for the IBM PC/XT/ AT. Chicago, SPSS Inc., 1986, pp. B177-B195. 3. Rooks, W. H.: The pharmacologie activity of ketorolac tromethamine. Pharmacotherapy 10:30S, 1990.
Corynebacterium Scleritis Ronald Caronia, M.D., Jeffrey Liebmann, M.D., Mark Speaker, M.D., and Robert Ritch, M.D. Department of Ophthalmology, New York Eye and Ear Infirmary, and New York Medical College. Sup ported in part by The Glaucoma Foundation, New York, New York. Inquiries to Ronald M. Caronia, M.D., Glaucoma Serv ice, New York Eye and Ear Infirmary, 310 E. 14th St., New York, NY 10003. Various bacteria, viruses, fungi, and parasites have been reported as etiologic agents of infec tious scleritis. 1 Infections of the sciera are often difficult to manage and eradicate, but improved success has been achieved with surgical inter vention in addition to antimicrobial therapy. 2 Diphtheroids have only recently been recog nized as ocular pathogens. 3 We evaluated a case of bacterial scleritis caused by a Corynebacteri um species, or diphtheroid, which responded well to intensive medical and surgical therapy. A 73-year-old white woman with systemic hypertension was referred for management of open-angle glaucoma. Best-corrected visual acuity in both eyes was 20/25 and the intraocu lar pressure was 24 mm Hg in both eyes. The cup/disk ratio was 0.95 in both eyes. Perimetry disclosed bilateral small central islands of vi sion. A trabeculectomy was performed in the right eye. The postoperative course was un eventful. Thirteen months after surgery, the patient returned because of a three-week history of ocular discomfort and redness of the right eye. The visual acuity was counting fingers at 3 feet. Examination of the right eye disclosed a flat bleb superiorly and a raised injected area over the temporal conjunctiva. A cataract was pres ent. A diagnosis of episcleritis was made. Prednisolone acetate, four times a day in the right eye, and aspirin were initiated. During the following two months, the in flamed area developed into a raised, yellow subconjunctival lesion approximately 5 mm in diameter. The overlying conjunctiva became
Figure (Caronia and associates). Necrotic material overlying the ulcer bed. ulcerated, and necrotic material occupied the ulcer bed (Figure). Cultures of this material grew Corynebacterium species, a diphtheroid. No other organism was isolated. Debridement and cryotherapy of the lesion were performed in the operating room. Antibi otic therapy consisted of subconjunctival gentamicin, 20 mg, and vancomycin, 25 mg, a five-day course of intravenous gentamicin and cefazolin, and fortified topical carbenicillin and gentamicin. Topical fluorometholone was be gun three days after the procedure. Over the next several months, the topical antibiotics were tapered and discontinued. Follow-up disclosed reepithelialization of the overlying conjunctiva with resolution of the inflammatory process. Four months later, the patient underwent an extracapsular cataract extraction with posterior chamber intraocular lens implantation in the right eye. Two years later the visual acuity remained 20/30 in the right eye, without evidence of inflammation. The intraocular pressure was 13 mm Hg. The salient features of this case are the isolat ed organism being a Corynebacterium species, the site of scleritis occurring at a nonviolated area of the globe, and the successful outcome of our treatment modality. This is a unique case of a diphtheroid as an etiologic agent of bacterial scleritis. 1 There have been relatively few documented cases implicat ing diphtheroids as an ocular pathogen. 3 Infec tious keratitis is the most common manifesta tion of diphtheroid infections, 3 although there are reported cases of endophthalmitis. 4 Rubinfeld and associates 3 observed that a pre-existing condition which compromised the ocular surface was present in their cases of corneal ulcération caused by diphtheroids. The predisposition in our patient is not as certain since the site of infection occurred at a location
406
AMERICAN JOURNAL OF OPHTHALMOLOGY
March, 1994
distant from the filtering bleb. Possibly, the presence of the filtering bleb, the use of ocular medications, or unrecognized trauma altered the conjunctiva to permit transconjunctival mi gration of these low virulent bacteria. The success rate for treatment of infectious scleritis with antibiotic therapy alone is poor. 2 Reynolds and Alfonso 2 reported on the advan tages of a combined surgical debridement and cryotherapy in the treatment of infectious scle ritis. Implementing this treatment modality, we were able to resolve the infection, maintain good visual potential, and preserve the func tion of the filtering bleb.
References 1. Jackson, W. B.: Infections of the sciera. In Tabbara, K. F., and Hyndiuk, R. A. (eds.): Infections of the Eye. Boston, Little, Brown and Company, 1986, p. 477. 2. Reynolds, M. G., and Alfonso, E.: Treatment of infectious scleritis and keratoscleritis. Am. J. Ophthalmol. 112:543, 1991. 3. Rubinfeld, R. S., Cohen, E. J., Arentsen, J. J., and Laibson, P. R.: Diphtheroids as ocular patho gens. Am. J. Ophthalmol. 108:251, 1989. 4. Hanscom, T., and Maxwell, W. A.: Corynebacterium endophthalmitis. Laboratory studies and report of a case treated by vitrectomy. Arch. Ophthalmol. 97:500, 1979.
Cytomegalovirus Infection of the Caruncle in the Acquired Immunodeficiency Syndrome E. Espafta-Gregori, M.D., F. J. Vera-Sempere, M.D., J. Cano-Parra, M.D., V. Ramos-Fernandez, M.D., A. Navea-Tejerina, M.D., and M. D i a z - L l o p i s , M.D. Departments of Ophthalmology (E.E.-G., J.C.-P., A.N.-T., M.D.-L.) and Pathology (F.J.V.-S., V.R.-F.), "La Fe" University Hospital. Inquiries to E. Espafta-Gregori, M.D., Plaza Fray Luis Colomer 8-36, 46021 Valencia, Spain. Cytomegalovirus is the most common ocular opportunistic infectious agent in patients with acquired immunodeficiency syndrome (AIDS). It causes a necrotizing retinopathy, but only rarely infects ocular tissues other than the reti na. 1 Several cases of conjunctival infection have been reported. 2 We treated a patient with histo-
Fig. 1 (Espana and associates). Anterior segment shows hyperemia of the left caruncle with normal conjunctiva. pathologic evidence of cytomegalovirus infec tion of the caruncle. A 58-year-old homosexual man with AIDS developed cytomegalovirus retinopathy in his right eye eight months before death, which responded to intravenous foscarnet therapy. The patient had mild ocular discomfort, espe cially in his left eye, which occurred three weeks before death. Anterior segment examina tion disclosed hyperemia of his left caruncle with normal conjunctiva (Fig. 1). A biopsy of that left caruncle was performed under local anesthesia. Histopathologic examination showed cytomegalic intranuclear inclusion cells (Fig. 2, left). Immunohistochemical stud ies demonstrated positive staining for cytomeg alovirus antigen, while staining for herpesvirus types I and II was negative (Fig. 2, right). Cytomegalovirus has been identified in the conjunctiva of selected AIDS patients, but is not believed to cause clinical disease. 2 In one reported case, histopathologic examination dis closed cytomegalic cells surrounding and mi grating through the walls of dilated conjuncti val vessels, 2 suggesting a dissemination of cytomegalovirus to the eye via the blood stream. Shedding of cytomegalovirus has been reported in tears of immunosuppressed pa tients, thus providing another source of con junctival infection. 3 Whether viral shedding represents a source of contagious virus for spread of the disease is unknown. In another case, herpetic viral particles were present in a random conjunctival biopsy specimen from a patient with AIDS.4 There was no evidence of conjunctival infection, nor was it known if the
Letters to The Journal
405
2. Norusis, M. J.: SPSS/PC+ for the IBM PC/XT/ AT. Chicago, SPSS Inc., 1986, pp. B177-B195. 3. Rooks, W. H.: The pharmacologie activity of ketorolac tromethamine. Pharmacotherapy 10:30S, 1990.
Corynebacterium Scleritis Ronald Caronia, M.D., Jeffrey Liebmann, M.D., Mark Speaker, M.D., and Robert Ritch, M.D. Department of Ophthalmology, New York Eye and Ear Infirmary, and New York Medical College. Sup ported in part by The Glaucoma Foundation, New York, New York. Inquiries to Ronald M. Caronia, M.D., Glaucoma Serv ice, New York Eye and Ear Infirmary, 310 E. 14th St., New York, NY 10003. Various bacteria, viruses, fungi, and parasites have been reported as etiologic agents of infec tious scleritis. 1 Infections of the sciera are often difficult to manage and eradicate, but improved success has been achieved with surgical inter vention in addition to antimicrobial therapy. 2 Diphtheroids have only recently been recog nized as ocular pathogens. 3 We evaluated a case of bacterial scleritis caused by a Corynebacteri um species, or diphtheroid, which responded well to intensive medical and surgical therapy. A 73-year-old white woman with systemic hypertension was referred for management of open-angle glaucoma. Best-corrected visual acuity in both eyes was 20/25 and the intraocu lar pressure was 24 mm Hg in both eyes. The cup/disk ratio was 0.95 in both eyes. Perimetry disclosed bilateral small central islands of vi sion. A trabeculectomy was performed in the right eye. The postoperative course was un eventful. Thirteen months after surgery, the patient returned because of a three-week history of ocular discomfort and redness of the right eye. The visual acuity was counting fingers at 3 feet. Examination of the right eye disclosed a flat bleb superiorly and a raised injected area over the temporal conjunctiva. A cataract was pres ent. A diagnosis of episcleritis was made. Prednisolone acetate, four times a day in the right eye, and aspirin were initiated. During the following two months, the in flamed area developed into a raised, yellow subconjunctival lesion approximately 5 mm in diameter. The overlying conjunctiva became
Figure (Caronia and associates). Necrotic material overlying the ulcer bed. ulcerated, and necrotic material occupied the ulcer bed (Figure). Cultures of this material grew Corynebacterium species, a diphtheroid. No other organism was isolated. Debridement and cryotherapy of the lesion were performed in the operating room. Antibi otic therapy consisted of subconjunctival gentamicin, 20 mg, and vancomycin, 25 mg, a five-day course of intravenous gentamicin and cefazolin, and fortified topical carbenicillin and gentamicin. Topical fluorometholone was be gun three days after the procedure. Over the next several months, the topical antibiotics were tapered and discontinued. Follow-up disclosed reepithelialization of the overlying conjunctiva with resolution of the inflammatory process. Four months later, the patient underwent an extracapsular cataract extraction with posterior chamber intraocular lens implantation in the right eye. Two years later the visual acuity remained 20/30 in the right eye, without evidence of inflammation. The intraocular pressure was 13 mm Hg. The salient features of this case are the isolat ed organism being a Corynebacterium species, the site of scleritis occurring at a nonviolated area of the globe, and the successful outcome of our treatment modality. This is a unique case of a diphtheroid as an etiologic agent of bacterial scleritis. 1 There have been relatively few documented cases implicat ing diphtheroids as an ocular pathogen. 3 Infec tious keratitis is the most common manifesta tion of diphtheroid infections, 3 although there are reported cases of endophthalmitis. 4 Rubinfeld and associates 3 observed that a pre-existing condition which compromised the ocular surface was present in their cases of corneal ulcération caused by diphtheroids. The predisposition in our patient is not as certain since the site of infection occurred at a location
406
AMERICAN JOURNAL OF OPHTHALMOLOGY
March, 1994
distant from the filtering bleb. Possibly, the presence of the filtering bleb, the use of ocular medications, or unrecognized trauma altered the conjunctiva to permit transconjunctival mi gration of these low virulent bacteria. The success rate for treatment of infectious scleritis with antibiotic therapy alone is poor. 2 Reynolds and Alfonso 2 reported on the advan tages of a combined surgical debridement and cryotherapy in the treatment of infectious scle ritis. Implementing this treatment modality, we were able to resolve the infection, maintain good visual potential, and preserve the func tion of the filtering bleb.
References 1. Jackson, W. B.: Infections of the sciera. In Tabbara, K. F., and Hyndiuk, R. A. (eds.): Infections of the Eye. Boston, Little, Brown and Company, 1986, p. 477. 2. Reynolds, M. G., and Alfonso, E.: Treatment of infectious scleritis and keratoscleritis. Am. J. Ophthalmol. 112:543, 1991. 3. Rubinfeld, R. S., Cohen, E. J., Arentsen, J. J., and Laibson, P. R.: Diphtheroids as ocular patho gens. Am. J. Ophthalmol. 108:251, 1989. 4. Hanscom, T., and Maxwell, W. A.: Corynebacterium endophthalmitis. Laboratory studies and report of a case treated by vitrectomy. Arch. Ophthalmol. 97:500, 1979.
Cytomegalovirus Infection of the Caruncle in the Acquired Immunodeficiency Syndrome E. Espafta-Gregori, M.D., F. J. Vera-Sempere, M.D., J. Cano-Parra, M.D., V. Ramos-Fernandez, M.D., A. Navea-Tejerina, M.D., and M. D i a z - L l o p i s , M.D. Departments of Ophthalmology (E.E.-G., J.C.-P., A.N.-T., M.D.-L.) and Pathology (F.J.V.-S., V.R.-F.), "La Fe" University Hospital. Inquiries to E. Espafta-Gregori, M.D., Plaza Fray Luis Colomer 8-36, 46021 Valencia, Spain. Cytomegalovirus is the most common ocular opportunistic infectious agent in patients with acquired immunodeficiency syndrome (AIDS). It causes a necrotizing retinopathy, but only rarely infects ocular tissues other than the reti na. 1 Several cases of conjunctival infection have been reported. 2 We treated a patient with histo-
Fig. 1 (Espana and associates). Anterior segment shows hyperemia of the left caruncle with normal conjunctiva. pathologic evidence of cytomegalovirus infec tion of the caruncle. A 58-year-old homosexual man with AIDS developed cytomegalovirus retinopathy in his right eye eight months before death, which responded to intravenous foscarnet therapy. The patient had mild ocular discomfort, espe cially in his left eye, which occurred three weeks before death. Anterior segment examina tion disclosed hyperemia of his left caruncle with normal conjunctiva (Fig. 1). A biopsy of that left caruncle was performed under local anesthesia. Histopathologic examination showed cytomegalic intranuclear inclusion cells (Fig. 2, left). Immunohistochemical stud ies demonstrated positive staining for cytomeg alovirus antigen, while staining for herpesvirus types I and II was negative (Fig. 2, right). Cytomegalovirus has been identified in the conjunctiva of selected AIDS patients, but is not believed to cause clinical disease. 2 In one reported case, histopathologic examination dis closed cytomegalic cells surrounding and mi grating through the walls of dilated conjuncti val vessels, 2 suggesting a dissemination of cytomegalovirus to the eye via the blood stream. Shedding of cytomegalovirus has been reported in tears of immunosuppressed pa tients, thus providing another source of con junctival infection. 3 Whether viral shedding represents a source of contagious virus for spread of the disease is unknown. In another case, herpetic viral particles were present in a random conjunctival biopsy specimen from a patient with AIDS.4 There was no evidence of conjunctival infection, nor was it known if the