Contact Lens-associated Nocardial Necrotizing Scleritis
A 52 year-old male presented with four weeks of pain, photophobia and redness in the right eye. The patient had been evaluated by three different ophthalmologists prior to his presentation and was referred for further management of a steroid unresponsive scleritis. The patient had been treated with topical ciprofloxacin 0.3%, Predforte 1%, and 80 mg of oral prednisone without improvement over a two-week period.\nThe patient's past medical history was significant for gout and hypertension. The patient was diagnosed with gout 25 years previous, and he averaged 1-2 gouty attacks in his feet each year. He denied smoking or alcohol/drug use and any history of ocular surgery or trauma. The patient worked as a plumber and had worn soft disposable contact lenses for 20 years. He stated that he was compliant with proper contact lens care.\nOn examination, the patient's visual acuity was 20 / 100 in the right eye and 20 / 20 in the left eye. He had moderate right eyelid edema. Extraocular muscles and confrontation visual fields were normal in both eyes. His pupils reacted normally, and his intraocular pressure was 12 mmHg in the right eye and 14 mmHg in the left eye. On slit lamp examination with attention to the right eye, the conjunctiva was heavily injected. There was an 8 × 4 mm avascular patch of sclera at 9 o'clock with supprative inflammatory debris encasing the temporal conjunctiva. There were moderate Descemet's folds on the temporal cornea, but no evidence of either keratitis or an epithelial defect. There was neovascularization of the peripheral cornea at 10 o'clock. The anterior chamber was without cells or flare, and there were no keratic precipitates present. These negative findings are illustrated in . The posterior segment was within normal limits in both eyes.\nPreviously performed serology demonstrated a normal complete blood count, comprehensive metabolic panel, uric acid level, and urinalysis. Antinuclear antibodies, rheumatoid factor, antineutrophil cytoplasmic antibodies, and anti-double stranded DNA antibodies were also negative. The patient was diagnosed with necrotizing scleritis, poorly responsive to moderately high doses of oral steroids. Autoimmune, metabolic, and infectious causes were all considered. A swab culture of the supprative material coating the conjunctiva of the right eye was performed. A chest X-ray, lysozyme, rapid plasma reagin, venereal disease research laboratory, immunoglobulin A/immunoglobulin G for varicella zoster virus and herpes simplex virus, and thyroid-stimulating hormone tests were ordered. The patient was continued on the 80 mg of oral prednisone and referred to a rheumatologist for consideration of cyclophosphamide induction pending negative culture and laboratory results.\nAt five days follow-up from initial presentation, there was no significant change in the patient's symptoms or examination. The chest X-ray and the above mentioned labs were within normal limits. However, the culture came back positive for Nocardia asteroides, for which the patient was started on oral Bactrim DS twice daily and topical 2.5% amikacin every two hours. The prednisone dose was reduced to 40 mg, and a tapering schedule was implemented.\nAt one-week follow-up from the positive culture, there was significant improvement in the patient's symptoms and labs. His visual acuity improved to 20 / 40, and he was subjectively less photophobic and without significant pain. The culture results demonstrated that the Nocardia asteroides complex was sensitive to both amikacin and Bactrim, as shown in .\nAt one-month follow-up, the patient's visual acuity was 20 / 25 and he remained pain-free. The patient was tapered off the oral prednisone, and his topical amikacin was reduced to twice daily. At three months follow-up, the patient's right eye was refracted to 20 / 20 and he remained pain-free. The topical amikacin and oral Bactrim were discontinued. These results are illustrated in . The patient continued to be infection-free at his one-year follow-up examination.