Peripheral keratitis associated with chronic myelomonocytic leukemia

PURPOSE: To describe a case of peripheral keratitis in a patient with an acute exacerbation of chronic myelomonocytic leukemia (CMML). METHOD: Case report and review of the literature. RESULTS: This is the second reported case of peripheral keratitis in a patient with CMML. The previously reported patient presented with peripheral keratitis that led to the diagnosis of leukemia. Our patient had an established diagnosis of CMML, and peripheral keratitis occurred during an acute exacerbation of his chronic leukemia. The keratitis resolved with topical corticosteroids in our patient. CONCLUSION: Leukemia should be included in the differential diagnosis of peripheral keratitis. Elevated white blood cell count with abnormal differential in a patient with peripheral keratitis may help to establish a diagnosis of leukemia or identify an acute exacerbation of chronic leukemia.     

Peripheral keratitis associated with erythema elevatum diutinum

PURPOSE: To describe a case of peripheral keratitis associated with erythema elevatum diutinum (EED), an unusual immune-complex-mediated cutaneous vasculitis. DESIGN: Observational case report. METHODS: A 25-year-old man who was diagnosed 15 months previously with erythema elevatum diutinum presented with an inflammatory peripheral keratitis of the left eye. RESULTS: Serologic investigations for systemic disorders associated with vasculitic peripheral ulcerative keratitis were unremarkable. As the sclerokeratitis was thought to represent an ocular extension of the patient's cutaneous vasculitis, dapsone therapy was initiated and resulted in a rapid response of both the cutaneous and the ocular inflammation. CONCLUSIONS: Erythema elevatum diutinum should be included in the differential diagnosis of vasculitic peripheral keratitis.     

Acanthamoeba as a cause of peripheral ulcerative keratitis

PURPOSE: To report a case of peripheral ulcerative keratitis caused by Acanthamoeba. METHODS: Case report and review of the literature. A 37-year-old woman with a history of pain and redness of the right eye with no apparent predisposing factors, on examination, revealed a peripheral ulcerative keratitis. RESULT: Microbiological investigations of the corneal infiltrate revealed Acanthamoeba cysts. CONCLUSION: All cases of peripheral ulcerative keratitis should be subjected to routine microbiological evaluation including those for Acanthamoeba.     

Recurrent herpetic keratouveitis following YAG laser peripheral iridotomy

OBJECTIVE: To report recurrent herpetic keratouveitis following YAG laser peripheral iridotomy. METHODS: Case report. RESULTS: A 64-year-old woman with a history of dendritic keratitis underwent Nd:YAG laser peripheral iridotomy and developed geographic epithelial keratitis with stromal keratouveitis. Culture of a corneal swab grew herpes simplex virus type I. Keratouveitis subsided with acyclovir and corticosteroid therapy. CONCLUSIONS: Recurrent herpetic keratouveitis may be induced by YAG laser iridotomy.     

Peripheral ulcerative keratitis-like findings associated with filgrastim

PURPOSE: To describe an ocular side effect occurring with filgrastim therapy. METHODS: Retrospective case report. RESULTS: One week after starting therapy with intravenous filgrastim, a 66-year-old woman developed bilateral keratitis, evidenced by epithelial defects and peripheral corneal infiltrates. When filgrastim was discontinued, symptoms improved within 3 days and resolved within 2 weeks. CONCLUSIONS: Our patient's bilateral keratitis, which abated rapidly after discontinuation of filgrastim, may have been an adverse effect of this drug. Although the patient also took pamidronate, timing and resolution of symptoms make this a less likely culprit. Physicians should be aware of the possibility of filgrastim-associated keratitis, which can be managed by discontinuing the drug or treating with artificial tears.     

Nodular scleritis and panuveitis with erythema elevatum diutinum

PURPOSE: To report a case of nodular scleritis and panuveitis associated with erythema elevatum diutinum, a rare immunocomplex-mediated skin disease. DESIGN: Observational case report. METHODS: A 22-year-old woman who was diagnosed with erythema elevatum diutinum developed nodular scleritis and panuveitis of the right eye. She had experienced peripheral ulcerative keratitis with corneal perforation. RESULTS: All other known causes of nodular scleritis and panuveitis were investigated and ruled out. CONCLUSIONS: Erythema elevatum diutinum should be considered as an underlying systemic disease associated with nodular scleritis and panuveitis as well as peripheral keratitis.     

Bilateral peripheral infiltrative keratitis after LASIK

PURPOSE: To report a case of peripheral infiltrate between the flap edge and limbus, which appeared on the first postoperative day after laser in situ keratomileusis (LASIK). METHODS: A 22-year-old man underwent uneventful bilateral simultaneous LASIK but developed a thick band of infiltrate between the flap margin and limbus extending from 2 o'clock to 9 o'clock in both eyes. The flap edge was not involved. The infiltrate was more concentrated at the periphery and faded centrally and progressed diffusely into the interface leading to typical diffuse lamellar keratitis. RESULTS: The infiltrate responded to topical prednisolone acetate 1% eye drops. CONCLUSIONS: This entity was referred to as LASIK-induced bilateral peripheral infiltrative keratitis with a probable immune-mediated etiology.     

A case of peripheral ulcerative keratitis associated with neutrophilic dermatosis of the dorsal hand

We report a case of peripheral ulcerative keratitis associated with neutrophilic dermatosis of the dorsal hand, a recently described clinical entity. A 68-year-old man presented with concurrent peripheral ulcerative keratitis of the right eye and neutrophilic dermatosis of the dorsal hand causing pustular skin eruptions on the dorsal surface of both hands. Systemic investigations suggested an underlying diagnosis of Wegener's granulomatosis. To our knowledge this is the first reported case of neutrophilic dermatosis of the dorsal hand associated with ocular complications.     

Ocular presentation in Wegener granulomatosis

CASE REPORT: A 71 year-old female presented with bilateral conjunctivitis, scleritis and peripheral ulcerative keratitis. Ancillary tests showed presence of anti-neutrophil cytoplasmic antibodies, with diffuse granular cytoplasmic immunofluorescence staining (ANCAc). Conjunctival biopsy showed necrotizing vasculitis in small vessels. Diagnosis of Wegener Granulomatosis (WG) was established and upper respiratory affection detected. Treatment with megadoses of cyclophosphamide and corticoids was initiated and remission of the disease was obtained. DISCUSSION: WG is a potentially lethal systemic vasculitis in which ocular involvement may be the first clinical presentation. Scleritis and peripheral ulcerative keratitis indicate systemic involvement, highlighting the importance of prompt diagnosis and treatment.     

Peripheral ulcerative keratitis and central retinal vein occlusion as the initial manifestation of HIV infection

PURPOSE: To report a case of peripheral ulcerative keratitis and central vein occlusion as the initial manifestation of HIV infection. METHOD: Case report. RESULT: A 46-year-old male presented with history of pain, redness, and diminished vision of left eye. Examination revealed left eye peripheral ulcerative keratitis (PUK) and right eye central retinal vein occlusion (CRVO). The patient was found to be positive for HIV on serological evaluation. CONCLUSION: Atypical ophthalmic manifestations may be the initial presenting feature in patients with HIV infection. This highlights the need for increased index of suspicion for HIV infection in young patients with PUK and/or CRVO.     

Effective steroid-sparing treatment for peripheral ulcerative keratitis and pyoderma gangrenosum

OBJECTIVE: To report a patient with a rare clinical presentation of marginal keratitis and pyoderma gangrenosum (PG) that responded to the steroid-sparing agent azathioprine. DESIGN: Interventional case report. METHODS: Case report and MEDLINE review of the medical literature on PG-associated peripheral ulcerative keratitis (PUK) and its treatment. RESULTS: A patient with a biopsy-proven history of PG developed an explosive episode of PUK. The ocular inflammation was minimally responsive to topical therapy and required significant long-term oral steroids for control. The patient's active skin lesions and marginal keratitis responded dramatically to systemic oral azathioprine. Since the initiation of treatment with azathioprine, there have been no subsequent recurrences of PG or marginal keratitis. CONCLUSIONS: PUK may be associated with other inflammatory conditions, such as PG and arthritis. Systemic azathioprine may successfully control ocular and extraocular conditions and should be considered in the clinical setting of topical therapy failure and/or extraocular inflammatory conditions.     

Syphilitic interstitial keratitis: treatment with immunosuppressive drug combination therapy

OBJECTIVE: The following is a case presentation of congenital syphilitic keratitis in a boy 6 years of age who was successfully treated with an immunosuppressive drug combination therapy. METHODS: Congenital syphilitic keratitis was diagnosed by clinical findings and laboratory tests. The child was unresponsive to traditional treatment; thus, systemic immunosuppressive therapy, which consisted of oral cyclosporine 4 mg/kg/d, 6 days per week, and oral low-dose steroids (fluocortolone 0.8 mg/kg a week, given every other day), was initiated. RESULTS: Corneal disease showed great improvement with this therapy, with progressive healing of lesions in the first month of treatment and no signs of toxic renal, hepatic, or growth abnormalities. Recurrences of uveitis have not occurred, and corneal interstitial keratitis episodes have been limited to 3 in an 8-year period. After 6 months with no recurrences, a tapering off of the systemic therapy was initiated, and the child is still asymptomatic and without flare-ups. CONCLUSIONS: Congenital syphilitic keratitis is usually treated with topical steroids and cycloplegic drugs, which not only can be ineffective but can also lead to complications such as cataract and glaucoma. In the present case report, a pediatric patient affected by syphilitic interstitial keratitis was treated successfully with an immunosuppressive drug combination therapy.     

Successful treatment of Paecilomyces lilacinus keratitis in a patient with a history of herpes simplex virus keratitis

PURPOSE: To report a case of Paecilomyces lilacinus keratitis, initially misdiagnosed as Penicillium sp., in a patient with a long-standing history of herpes simplex virus (HSV) keratitis. METHODS: A retrospective case report. RESULTS: A 62-year-old man developed P. lilacinus keratitis. He was treated with topical steroids for immune stromal keratitis secondary to HSV before developing the fungal keratitis. Initial corneal cultures were positive for Penicillium sp., but subsequent cultures identified P. lilacinus to be the causative organism. The patient later developed an anterior chamber abscess. Three penetrating keratoplasties, as well as intravitreal injection of amphothericin B, topical miconazole, subconjunctival miconazole, and systemic fluconazole, were required to eradicate the infection. CONCLUSION: To our knowledge, this is a first report of P. lilacinus keratitis in a patient with a previous history of HSV keratitis. The causative organism was initially reported as Penicillium sp. on 2 occasions, before the correct diagnosis was made. Paecilomyces keratitis progressed to an anterior chamber abscess in this eye. Aggressive treatment, including a therapeutic penetrating keratoplasty, intravitreal amphothericin B injection, topical miconazole, and systemic fluconazole can be successful in eradicating this extremely difficult-to-treat infection.     

Rapid species determination of Nocardia keratitis using pyrosequencing technology

PURPOSE: To describe a new technique, pyrosequencing, which allows for the rapid identification of Mycobacterium and Nocardia species. DESIGN: Interventional case report. METHODS: The medical records of a patient presenting with an infectious keratitis were reviewed. RESULTS: A case of Nocardia abscessus/arthrititis/asiatica keratitis was diagnosed in a young individual with the aid of pyrosequencing technology. Based on presumed antibiotic sensitivities, therapy with topical trimethoprim-sulfamethoxazole eyedrops was initiated, and the infection was cleared rapidly with minimal residual scarring. CONCLUSIONS: Pyrosequencing may be a useful tool in aiding the rapid diagnosis and treatment of ocular infections caused by slow-growing pathogens.     

Marginal keratitis associated with administration of filgrastim and sargramostim in a healthy peripheral blood progenitor cell donor

PURPOSE: To describe a 61-year-old healthy peripheral blood progenitor cell (PBPC) donor who developed marginal keratitis and mild uveitis on the third day after receiving daily recombinant human granulocyte colony-stimulating factor (rhG-CSF; filgrastim) and recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF; sargramostim) to mobilize PBPCs for allogeneic transplantation. METHODS: Interventional case report. RESULTS: The keratitis was treated with topical administration of 1% prednisolone acetate solution and resolved within 24 hours. The topical steroid dose was tapered and ultimately discontinued without recurrence of keratitis. CONCLUSION: Healthy PBPC donors receiving rhG-CSF or rhGM-CSF should be monitored for ocular complications, particularly marginal keratitis and uveitis.     

Aspergillus fumigatus keratitis with wreath pattern infiltrates.

PURPOSE: To report a case of Aspergillus fumigatus keratitis with clinical features simulating Nocardia keratitis and to highlight the utility of microbiologic investigation in the successful management of infectious keratitis. METHOD: Case report. RESULTS: A 62-year-old man presented with complaints of pain, redness, and watering of 10 days' duration in his right eye. Direct microscopic observation of smears of corneal scrapings revealed a fungal etiology. The patient was treated with 5% natamycin eye drops and 1% atropine sulphate eye drops and was advised to visit the hospital for observation. During his visit to the hospital on day 10 after medication, the eye demonstrated a wreath pattern corneal infiltrate that simulated Nocardia keratitis. The fungus grown from culture of corneal scraping was identified as A. fumigatus. CONCLUSION: This report highlights the significance of subjecting corneal scrapings from suspected cases of infectious keratitis to microbiologic evaluation and emphasizes the fact that a complete microbiologic work-up helps in establishing a definitive etiologic diagnosis and initiating specific antimicrobial therapy.     

Bilateral non-resolving punctate keratitis in a keratoplasty patient

This study aimed to report a case of non-resolving bilateral coarse punctate keratitis in a patient with prior bilateral penetrating keratoplasty. In view of non-response to antivirals, corneal epithelial scraping was carried out, which revealed the presence of microsporidial cysts. The infection resolved after a period of 12 days following the diagnosis, during which steroids were discontinued. Microsporidial keratitis needs to be considered in non-resolving coarse punctate keratitis and microbiologic evaluation is essential to establish the diagnosis.     

Pellucid marginal degeneration and scleroderma

Systemic scleroderma is a progressive multi‐system connective tissue disease. Ocular involvement includes keratoconjunctivitis sicca, progressive shallowing of conjunctival fornices, peripheral ulcerative keratitis and eyelid tightness. No association has been reported between scleroderma and pellucid marginal degeneration, which is a rare bilateral corneal ectasia. Pellucid marginal degeneration is characterised by noninflammatory and progressive peripheral corneal thinning inferiorly, often with high against‐the‐rule astigmatism. We report a case of a 55‐year‐old woman with systemic scleroderma who presented with rapidly progressing against‐the‐rule astigmatism. The differential diagnosis of peripheral corneal thinning and the challenge of the surgical management of pellucid marginal degeneration are briefly discussed.     

Peripheral ulcerative keratitis and necrotizing scleritis initiated by trauma in the setting of mixed cryoglobulinemia

Purpose

To report a case of peripheral ulcerative keratitis and necrotizing scleritis precipitated by trauma in a patient with mixed cryoglobulinemia due to hepatitis C viral infection.

Methods

Case report and literature review.

Results

A 62-year-old man with a history of mixed cryoglobulinemia developed an episode of necrotizing scleritis and peripheral ulcerative keratitis one month after repair of a traumatic scleral defect with patch grafting. This episode resolved following treatment with high-dose corticosteroids and the patient underwent successful repeat patch grafting along with a free conjunctival autograft. This is the second reported case of necrotizing scleritis and peripheral ulcerative keratitis associated with mixed cryoglobulinemia.

Conclusion

Ophthalmologists should be aware of the association between mixed cryoglobulinemia and necrotizing scleritis/peripheral ulcerative keratitis. Patients with this condition experiencing ocular trauma or undergoing ocular surgery should be monitored closely.Key words: Scleritis, Peripheral ulcerative keratitis, PUK, Mixed cryoglobulinemia, Hepatitis C     

Rhinosporidiosis and peripheral keratitis

Report of a case of peripheral keratitis caused by Rhinosporidium seeberi. The patient was seen in a referral practice. Corneal scraping was performed on a middle-aged female patient presenting with peripheral keratitis and progressive nasal obstruction that revealed spores suggestive of rhinosporidiosis. The patient was started on topical amphotericin B 0.15% eye drops. Ear, nose, and throat (ENT) examination showed presence of a polypoid lesion in the left nostril for which a polypectomy was performed. Histopathological examination confirmed rhinosporidiosis. Complete resolution of the keratitis was observed. Topical amphotericin B is an effective drug in the management of this condition. Keratitis secondary to rhinosporidial infection has not been described although occasional patients with limbal and scleral involvement have been reported. Corneal scraping was effective in helping us make a tentative diagnosis.