Subretinal abscess due to Nocardia farcinica infection

PURPOSE: Nocardia infection of the eye is uncommon. A case of choroidal abscess due to Nocardia farcinica infection is presented, and the literature is reviewed. METHODS: A 41-year-old immunocompromised man with chronic myeloid leukemia developed a unilateral choroidal abscess. N. farcinica was isolated from a simultaneous subcutaneous abscess and both infections responded to systemic sulfonamide therapy. RESULTS: Three weeks after discontinuation of the sulfonamides, the choroidal abscess recurred with involvement of the vitreous. The infection was brought under control after reinstitution of the same drug. CONCLUSIONS: Nocardiosis is a multisystem disease that has high mortality and ocular morbidity rates. The eyes of immunocompromised patients should be examined frequently as early detection and administration of the proper antibiotics may reduce the risk of this life-threatening infection.     

Subretinal abscess due to Nocardia farcinica resistant to trimethoprim- sulfamethoxazole in a patient with systemic lupus erythematosus

PURPOSE: To report a case of subretinal abscess due to Nocardia farcinica resistant to trimethoprim-sulfamethoxazole in a patient with systemic lupus erythematosus on immunosuppressive therapy. DESIGN: Observational case report. METHODS: We retrospectively studied the medical record of a patient with nocardiosis. RESULTS: The microorganism disseminated from the lungs (pneumonia) to the eye and brain. The ocular lesion appeared to be a yellowish, lobulated subretinal abscess with irregular surface and superficial retinal hemorrhages. As it was not responding to empiric therapy for nocardia, pars plana vitrectomy and aspiration of the subretinal material was performed to confirm the etiology. CONCLUSION: In an immunocompromised patient with pulmonary involvement and a subretinal abscess with a characteristic aspect, one should consider nocardia as a possible etiology taking into account its possible antibiotic resistances.     

Acanthamoeba sclerokeratitis: treatment with systemic immunosuppression

OBJECTIVE: This study describes the clinical features, management, and outcome of 19 patients who had severe Acanthamoeba sclerokeratitis (ASK) unresponsive to conventional management, requiring systemic immunosuppression to control disease. DESIGN: Retrospective, non-comparative, interventional case series. PARTICIPANTS: Records of all patients with Acanthamoeba keratitis treated at Moorfields Eye Hospital between 1989 and 2000 were reviewed. From more than 200 patients, 19 who developed ASK treated with systemic immunosuppression were identified. MAIN OUTCOME MEASURES: Visual acuity, level of pain, and degree of inflammation were recorded after immunosuppressive treatment. RESULTS: ASK requiring immunosuppression occurred in 20 eyes of 19 patients (11 males and 8 females). The mean age (mean +/- standard deviation) at onset was 38.6 +/- 13.2 years. On presentation, best-corrected visual acuity was counting fingers or worse in 11 eyes (55%), 6/18 to 6/60 in 5 eyes (25%), and 6/12 or better in 4 eyes (20%). The mean time between onset of initial symptoms of Acanthamoeba keratitis and commencement of systemic immunosuppression was 4.8 +/- 3.5 months. The mean duration of immunosuppression required to control inflammation was 7.2 +/- 3.9 months. Severe scleritic pain remained uncontrolled in two patients and resulted in enucleation. Best-corrected visual acuity at final follow-up was counting fingers or worse in eight eyes (40%), 6/18 to 6/60 in six eyes (30%), and 20/40 or better in six eyes (30%). The mean follow-up period after resolution of inflammation was 24.3 +/- 20.9 months (range, 0.2-59.7 months). CONCLUSIONS: ASK is an uncommon complication of Acanthamoeba keratitis. The scleritis associated with this infection seems to be an immune-mediated response. After topical amebicidal treatment, systemic immunosuppression may be required to control the pain and tissue destruction associated with ASK.     

Subretinal Abscess Due to Nocardia farcinica Resistant to Trimethoprim- Sulfamethoxazole in a Patient with Systemic Lupus Erythematosus

Purpose: To report a case of subretinal abscess due to Nocardia farcinica resistant to trimethoprim-sulfamethoxazole in a patient with systemic lupus erythematosus on immunosuppressive therapy. Design: Observational case report. Methods: We retrospectively studied the medical record of a patient with nocardiosis. Results: The microorganism disseminated from the lungs (pneumonia) to the eye and brain. The ocular lesion appeared to be a yellowish, lobulated subretinal abscess with irregular surface and superficial retinal hemorrhages. As it was not responding to empiric therapy for nocardia, pars plana vitrectomy and aspiration of the subretinal material was performed to confirm the etiology. Conclusion: In an immunocompromised patient with pulmonary involvement and a subretinal abscess with a characteristic aspect, one should consider nocardia as a possible etiology taking into account its possible antibiotic resistances.     

Nocardia choroidal abscess in a patient with systemic lupus erythematosus

Purpose: Nocardia asteroides, a respiratory saprophyte in humans, may cause localized infection of the lungs in debilitated or immunosuppressed individuals. Haematogenous spread to the eye via the choroidal circulation may result in choroidal abscess formation. Method: We report the development of a choroidal abscess in the left eye of a woman treated with steroids and cyclophosphamide for systemic lupus erythematosus. Haematogenous spread of N. asteroides from a localized infection of the lung (empyema) is thought to have been the cause of the choroidal abscess. Results: Surgical drainage of the empyema combined with intravenously administered antibiotics resulted in resolution of the choroidal abscess and improvement of vision. Conclusions: A choroidal abscess, caused by haematogenous spread of N. asteroides, may respond to appropriate systemic antibiotic treatment alone and not require ocular treatment.     

Endogenous Nocardia asteroides endophthalmitis in a patient with systemic lupus erythematosus.

We report a case of endogenous Nocardia endophthalmitis in a patient with systemic lupus erythematosus (SLE). He developed a parafoveal lesion in the right fundus while on systemic corticosteroid and antibiotic treatment. Initially we suspected a fungal origin and treated him with antifungal drugs. The intraocular disease progressed without improvement and advanced to the vitreous cavity. Nocardia asteroides was found in a specimen obtained at pars plana vitrectomy and was also cultured from the same specimen. The intraocular infection was controlled by antibacterial drugs, though the visual acuity of the right eye was reduced to only light perception owing to heavy vitreous opacity and secondary cataract. This case is the first report of endogenous Nocardia endophthalmitis in Japan and also the first case of this disease reported from outside the United States of America.     

Long-term follow-up of patients with birdshot retinochoroidopathy treated with systemic immunosuppression

PURPOSE: Birdshot retinochoroidopathy (BRC) is a rare uveitis syndrome of presumed autoimmune etiology. Therapy with systemic and periocular corticosteroids is of inconsistent efficacy, attendant with numerous potential long-term side effects. Corticosteroid-sparing strategies with agents such as cyclosporine A or azathioprine have been suggested for this disease. METHODS: We retrospectively reviewed the medical charts of patients with BRC who were evaluated consecutively at a tertiary-care, referral-based North American uveitis clinic over a 15-year period. RESULTS: Eleven Caucasian patients (22 eyes) were diagnosed with BRC, representing approximately 1% of all cases seen at the uveitis clinic. HLA-A29 was positive in all 11 patients. We elected to treat five patients with azathioprine, methotrexate, cyclosporine A, mycophenolate mofetil, and/or IvIg, as well as systemic or periocular corticosteroid injections. The median period of follow-up for the five treated patients was six years (range: 8 months-13 years). Inflammation was reduced or stabilized in five of five patients. CONCLUSION: Although the definitive strategy for the management of BRC is unknown, control of intraocular inflammation and preservation of vision is possible with corticosteroid-sparing immunosuppressive agents.     

内源性鼻疽诺卡菌眼内炎一例

患者,男,67岁。因“左眼突然眼痛、视力下降伴同 侧头痛10 d”于2019年12月30日在厦门大学附属厦门眼科 中心就诊。患者3个月余前四肢及躯干无明显诱因出现斑 块状皮下淤血（见图1）,就诊于当地医院,诊断为“过敏性 皮炎”,自诉涂抹“藏药”治疗2 个月后缓解（用药情况不 详）。近期患者体质量减轻约10 kg,常感乏力、头晕,病因不明。既往有高血压病、糖尿病以及肾病病史数年,药物 控制基本稳定。有青霉素、磺胺类药物过敏史。无眼部外伤史及手术史。眼部检查：矫正视力为右眼1.0,左眼手动/ 眼前10 cm。眼压：右眼14.4 mmHg（1 mmHg=0.133 kPa）, 左眼14.8 mmHg。左眼混合性充血,睫状压痛明显,角膜轻度水肿,少许色素性角膜后沉积物;前房深度正常,房水轻度浑浊,Tydnall（+）;瞳孔欠圆,直径约3.5 mm,部分后粘连。瞳孔区晶状体前囊见少许色素沉着,晶状体灰白色混浊,眼后节红光反射未见（见图2）。     

Nocardia endophthalmitis after cataract surgery: clinicomicrobiological study

PURPOSE: To analyze the clinical presentation, microbiological profile, and treatment outcome in cases of nocardial endophthalmitis after cataract surgery. DESIGN: Retrospective, observational case series. METHODS: setting: Tertiary referral hospital. patients: Retrospective analysis of 24 cases of culture-proven exogenous nocardial endophthalmitis following cataract surgery between January 2000 and December 2003. main outcome measures: Visual acuity and anatomic outcome. RESULTS: Visual outcome was poor in most patients, with 79% (19/24) of patients obtaining a final visual acuity of hand motions or worse and 46% (11/24) of patients with no light perception. Initial presenting visual acuity was strongly associated with final visual outcome (P = .0026). There was a statistically significant trend favoring better visual outcome in patients who presented early after the onset of symptoms (P = .01). The majority of the eyes (23/24) had an early onset with predominantly anterior segment involvement. Wound infection was noted in 46% (11/24) of the patients at presentation. Clinical features included scleral abscess, cotton ball exudates in the anterior chamber, fluffy exudates on the corneal endothelium, nodular exudates on the iris, and hypopyon. Among the specimens cultured, the highest positivity was seen with the anterior chamber aspirate (15/16 = 93.75%), which was significantly higher than the vitreous aspirate cultured (1/22 = 4.54%) (P = .001). CONCLUSION: Nocardia endophthalmitis after cataract surgery is an aggressive disease with poor visual prognosis. Early diagnosis and treatment with good visual acuity at presentation may be associated with better visual outcome.     

Use of corticosteroid sparing systemic immunosuppression for treatment of corticosteroid dependent optic neuritis not associated with demyelinating disease

AIM: To describe the authors' experience and that in the published literature regarding the use of corticosteroid sparing systemic immunosuppression for patients with corticosteroid dependent optic neuritis not associated with demyelinating disease. METHODS: The records of 10 patients from the authors' clinical database, and 38 patients from the published literature with corticosteroid dependent optic neuritis, were retrospectively reviewed to determine patient demographics, diagnosis, clinical course, and outcomes. These patients had recrudescence of symptoms, such as decreased vision and pain, with attempted taper of corticosteroid. Many of these patients also suffered side effects from systemic corticosteroid use such as weight gain and uncontrolled hyperglycaemia. Antimetabolites (for example, methotrexate and azathioprine), cyclosporine and/or alkylating agents (for example, cyclophosphamide and chlorambucil) were given to enable taper of corticosteroid while effectively controlling optic neuritis. RESULTS: The study included 43 women and 5 men: 17 patients with systemic lupus erythematosus, 12 patients with sarcoidosis, 3 with other systemic autoimmune diseases, and 16 with no clinically identifiable systemic association. 79% of all patients benefited from the use of systemic immunosuppression in that they had successful corticosteroid taper, control of inflammation, improvement in symptoms, and/or tolerance of adverse effects. Mild toxicity was common and 19% of patients, most often those taking cyclophosphamide, discontinued medication because of adverse effects. 24 of 28 (86%) patients on alkylators benefited clinically, while 20 of 29 (69%) patients on antimetabolites had clinical benefit. CONCLUSION: Systemic immunosuppression may be a safer and more effective treatment alternative to chronic oral corticosteroid use in cases of corticosteroid dependent optic neuritis not associated with demyelinating disease.     

Mortality rate in rheumatoid arthritis patients developing necrotizing scleritis or peripheral ulcerative keratitis. Effects of systemic immunosuppression

We performed a nonrandomized clinical trial comparing the ocular and systemic efficacy of cytotoxic immunosuppression with steroidal and nonsteroidal anti-inflammatory therapy in the care of 34 patients with rheumatoid arthritis who developed peripheral ulcerative keratitis and/or necrotizing scleritis. Nine of the 17 patients managed with conventional therapy died of a vascular-related event during the ten-year period of the study. In 13 of the 17 patients, the ocular inflammatory process progressed, and in 5 patients extraocular, although nonlethal, vasculitic lesions developed. One of 17 patients treated with long-term immunosuppressive therapy died during the ten-year follow-up period, and this death occurred after cytotoxic therapy was withdrawn. None of the patients on immunosuppressive regimens developed extraocular vasculitis while taking the drug, and none had progression of the ocular destructive lesion. The results of this study emphasize that the eye is a sensitive indicator for potentially lethal occult systemic vasculitis in patients with rheumatoid arthritis who develop peripheral ulcerative keratitis or necrotizing scleritis. Our mortality data strongly suggest that the use of cytotoxic drugs may alter favorably the general as well as the ocular prognosis in these patients.     

Cataract surgery under systemic anticoagulant therapy with coumarin

PURPOSE: To evaluate clinical outcome of cataract surgery under systemic anticoagulant therapy using coumarin. METHODS: This clinical interventional comparative nonrandomized study included 441 patients (441 eyes) consecutively undergoing standard phacoemulsification with clear cornea incision and topical anesthesia. The study group consisted of 21 (4.8%) patients for whom systemic coumarin therapy was continued despite surgery. The control group included 420 patients without anticoagulant coumarin therapy prior to surgery. Study group and control group did not vary significantly in age, preoperative visual acuity, axial length, refractive error, preoperative intraocular pressure, or surgeon. RESULTS: Frequency of intraoperative or postoperative hemorrhages, intraoperative complications such as posterior capsule rupture, postoperative visual acuity, and intraocular pressure did no vary significantly (p>0.30) between study group and control group. CONCLUSIONS: For patients under systemic coumarin therapy, the rate of surgical complications may not markedly be increased compared to patients without coumarin therapy, when standard phacoemulsification with clear cornea incisions is performed with topical anesthesia. Systemic coumarin therapy does not have to be stopped prior to cataract surgery.     

Nocardia keratitis after laser in situ keratomileusis: clinicopathologic correlation

A case of Nocardia asteroides keratitis occurring 3 weeks after laser in situ keratomileusis (LASIK) in a nontraumatized eye is reported. The patient presented with decreased vision, inflammation, and stromal melting of the LASIK flap, discrete infiltrates, and an anterior chamber cellular reaction. Cultures for acid-fast bacteria grew Nocardia asteroides after 5 days. Infection progressed despite treatment with topical antibiotics and eventually required penetrating keratoplasty (PKP). Postoperatively, the patient was placed on moxifloxacin, a fourth-generation flouroquinolone. The patient experienced a recurrence of Nocardia keratitis at the graft-host interface 2 months after the PKP. This eventually resolved with a combination of topical moxifloxacin and imipenem therapy.     

Human chorioretinal biopsy under controlled systemic hypotensive anaesthesia.

This paper describes a simplified technique for biopsy of the retina and choroid which had been used in 5 human volunteers. The biopsy was carried out in 4 immediately before enucleation of an eye for malignant melanoma and in 1 patient who was undergoing trabeculectomy for painful glaucoma associated with retinitis pigmentosa. A combination of intravenous mannitol and transient controlled systemic hypotension, induced under general anaesthesia with intravenous sodium nitroprusside, was used in 3 cases and resulted in no vitreous loss and minimal bleeding. In the 2 cases in which hypotension was not used bleeding was a definite problem, but no vitreous loss was experienced.     

Nocardia keratitis: species, drug sensitivities, and clinical correlation

PURPOSE: To correlate the clinical presentation and treatment outcome of Nocardia keratitis with the time to diagnosis, different species and with the drug sensitivity pattern. METHOD: Patients with Nocardia corneal ulcers were studied at a tertiary eye care center. Speciation of Nocardia isolates was done by sequencing the 16s rRNA gene. Clinical response to treatment was assessed by chart review. RESULTS: Twenty one (65.3%) patients presented within 15 days of the onset of symptoms with typical clinical features of Nocardia keratitis, ie, a ring-like distribution of superficial infiltrates in a wreath pattern. Eight patients (25%) who presented after 15 days and within 30 days had an ulcer resembling fungal keratitis. N. Cyriacigeorgica (n = 11; 34.37%), N. asteroides (n = 9; 28%), N. farcinica (n = 7; 22%,) and N. Otitidiscaviarum (n = 5; 16%). All the species had 100% sensitivity to amikacin, sulphamethoxazole, imipenem and co-trimoxazole. Time to diagnosis of the infection was significantly associated with the different types of clinical presentation; those presenting early having the typical clinical picture (P = 0.004). Patients (73%) presenting within 15 days showed a highest recovery rate. (P = 0.045). The recovery time of the patients when compared with species showed those who were infected with N. cyriageorgica had a healing time of less than 15 days. Clinically, healing was faster when treated with 2% amikacin. Visual outcome improved in fourteen patients (44%) and sixteen (50%) patients remained the same (P = 0.0001). CONCLUSION: Characteristic clinical picture of Nocardia is dependant on early presentation. It could be mistaken for fungal keratitis. Microbiological confirmation is important. Drug of choice for Nocardia keratitis is amikacin.