June 2022
Volume 63, Issue 7
Open Access
ARVO Annual Meeting Abstract  |   June 2022
Nocardia scleritis masked as post-operative inflammation
Author Affiliations & Notes
  • Matthew Schulgit
    Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
    Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, United States
  • Kimberly Baynes
    Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
  • Abel Hamdan
    Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
  • Danny Mammo
    Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
  • Sunil K Srivastava
    Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
  • Footnotes
    Commercial Relationships   Matthew Schulgit None; Kimberly Baynes None; Abel Hamdan None; Danny Mammo None; Sunil Srivastava Gilead, Eyevensys, Jcyte, Regeneron, Eyepoint, Zeiss, Bausch and Lomb, Sanofi, Allergan, Abbvie, Novartis, Code C (Consultant/Contractor), Gilead, Eyevensys, Eyepoint, Regeneron, Bausch, Code R (Recipient)
  • Footnotes
    Support  None
Investigative Ophthalmology & Visual Science June 2022, Vol.63, 3568 – A0455. doi:
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      Matthew Schulgit, Kimberly Baynes, Abel Hamdan, Danny Mammo, Sunil K Srivastava; Nocardia scleritis masked as post-operative inflammation. Invest. Ophthalmol. Vis. Sci. 2022;63(7):3568 – A0455.

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      © ARVO (1962-2015); The Authors (2016-present)

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Purpose : Nocardia scleritis is rare and can mimic other infectious species, needing specific medication which delays resolution. Early identification is integral to avoid permanent damage. This report describes two patients presenting with Nocardia scleritis that masked as post-surgical inflammation and were exacerbated by local steroids.

Methods : A retrospective chart review of patients with Nocardia scleritis. Demographics, clinical history, and outcomes were reviewed.

Results : Two cases were identified:

Case 1: A 71-year-old female s/p conjunctival biopsy with cryotherapy presented with eye pain, blurred vision. Oral corticosteroid and moxifloxacin initially resolved discomfort. Periocular steroids were delivered during corticosteroid taper. After several weeks, symptoms and visual acuity worsened leading to referral. Upon evaluation, visual acuity was counting fingers with scleral necrosis and ovoid dense hypopyon. Right eye anterior chamber paracentesis elucidated Nocardia, prompting initiation of systemic, topical, and intravitreal antibiotics (bactrim, topical linezolid and amikacin, and intravitreal amikacin). Clinical symptoms and exam significantly improved with antibiotic course with resolution of scleritis. Visual acuity remains poor due to cataract formation 4 months after diagnosis.

Case 2: A 62-year-old female presented for evaluation of chronic postoperative inflammation after a trabeculotomy with mitomycin 3 months prior. Postoperative course was complicated by persistent scleral and anterior chamber inflammation. A systemic workup revealed a positive HLA B27 antigen. Corticosteroids including systemic, IV, and periocular steroids were administered to control postoperative inflammation. Upon presentation, the visual acuity was hand motions with multiple ovoid hypopyons. Aqueous paracentesis revealed Nocardia species. Multiple intravitreal amikacin antibiotics were administered. Despite aggressive intravitreal and systemic antibiotics, the eye worsened and was enucleated.

Conclusions : Clinical presentation of Nocardia scleritis can be masked and exacerbated by local steroids. In cases of post-operative scleral inflammation, caution is advised prior to the use of local steroid injections. The indolent nature of Nocardia infection can lead to diagnostic delay. As surgical trauma can precede infection, early consideration of Nocardia is important when postoperative patients present with scleritic symptoms.

This abstract was presented at the 2022 ARVO Annual Meeting, held in Denver, CO, May 1-4, 2022, and virtually.


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