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Arkadiy Yadgarov, Mohammad Dastjerdi, Marco A Zarbin, Neelakshi Bhagat; Management of Endophthalmitis Associated with Keratoscleritis in Eyes with History of Pterygium Excision. Invest. Ophthalmol. Vis. Sci. 2015;56(7 ):4192.
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Severe endophthalmitis from infectious keratoscleritis is difficult to treat, necessitating enucleation in many refractory cases. Management of this entity has not been well defined. We describe the clinical course, management, and outcomes of three eyes with previous pterygium (PTG) surgery that developed severe infectious keratoscleritis and endophthalmitis.
Retrospective case series. Patients with a history of PTG who developed endophthalmitis from infectious keratoscleritis were included. A chart review was performed to gather ocular history, visual acuity (Va), clinical presentations, pathogenic organism, treatment, and visual outcome.
Three eyes from three patients who met criteria were identified. Two patients were female and one was male, with an average age of 62 years old. All eyes had a PTG removal greater than 5 years prior to presentation. All patients were on topical corticosteroids for presumed autoimmune scleritis. Presenting Va was light perception in two eyes and count fingers in the third. Exam of each eye revealed an area of sclera that was thinned, avascular, and necrotic at site of previous PTG excision. There was associated keratitis and hypopyon. Scleral scrapings grew Pseudomonas aeruginosa in two eyes, and mixed flora (Aspergillus and Pneumococcus) in the third. Ultrasonography revealed vitritis in all eyes. Immediate intravitreal antibiotics were injected in each eye, with one eye undergoing multiple injections and a limited core pars plana vitrectomy. All patients underwent a three-week course of IV antibiotics, followed by a week of oral antibiotics and several weeks of fortified topical antibiotics. Two patients had complete clinical resolution after prolonged antibiotic therapy, while one patient still has an active scleral ulcer with very slow improvement. Final Va was count fingers, light perception, and 20/70.
Infectious keratoscleritis in eyes with previous PTG surgery was characterized by a rapidly destructive course of scleral necrosis and thinning at the site of PTG excision that progressed to endophthalmitis. Early intravitreal injection and long term IV antibiotic therapy was necessary to stabilize clinical course. Clinical improvement was extremely slow and gradual. Enucleation was averted in all three cases.
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