Bascom Palmer Eye Institute Grand Rounds Jaclyn Kovach, MD Discussants Janet Davis, MD Richard Forster, MD

Bascom Palmer Eye InstituteBascom Palmer Eye InstituteGrand RoundsGrand Rounds

U N I V E R S I T Y O F

S C H O O L O F M E D IC IN E

Jaclyn Kovach, MDJaclyn Kovach, MD

DiscussantsDiscussantsJanet Davis, MDJanet Davis, MD

Richard Forster, MDRichard Forster, MD



““I have had redness and poor vision in I have had redness and poor vision in my right eye for the past 5 months.”my right eye for the past 5 months.”

Chief ComplaintChief Complaint

• Referred to the retina OD service because of Referred to the retina OD service because of retinal detachmentretinal detachment



History of Present IllnessHistory of Present Illness

• This 78yo gentleman was diagnosed This 78yo gentleman was diagnosed with inflammation in the right eye in with inflammation in the right eye in September 2006September 2006

• A few weeks prior, he thought that he A few weeks prior, he thought that he had suffered an insect bite near right had suffered an insect bite near right brow brow → lid erythema, edema→ lid erythema, edema

• Wiped eye with dirty hand while cutting Wiped eye with dirty hand while cutting grassgrass



History of Present IllnessHistory of Present Illness

• In October, cornea specialist began treating In October, cornea specialist began treating him for a corneal infection with Vigamox and him for a corneal infection with Vigamox and pred forte. pred forte.

• Over the past month (January), white nodules Over the past month (January), white nodules had developed OD and his vision sharply had developed OD and his vision sharply declined.declined.

• He saw a retina specialist the day prior to He saw a retina specialist the day prior to presentation and was diagnosed with an presentation and was diagnosed with an endophthalmitis. A vitreous tap was endophthalmitis. A vitreous tap was performed. No growth.performed. No growth.

• Patient denies any pain OD.Patient denies any pain OD.



Past Medical HistoryPast Medical History

• POHx: CEIOL OU 1998, uncomplicated. POHx: CEIOL OU 1998, uncomplicated. 20/20 OU following surgery20/20 OU following surgery

• PMHx: HTN, HypercholesterolemiaPMHx: HTN, Hypercholesterolemia• FMHx: no eye diseaseFMHx: no eye disease• ALL: NoneALL: None• Ocular Meds: Vigamox QID OD, 4 Ocular Meds: Vigamox QID OD, 4

month course of pred forte ended last month course of pred forte ended last weekweek

• Systemic Meds: Labetolol, VytorinSystemic Meds: Labetolol, Vytorin



Ophthalmologic ExaminationOphthalmologic Examination

• BCVA: LP, 20/20BCVA: LP, 20/20• CVF: unable OD, full OSCVF: unable OD, full OS• EOM: full OUEOM: full OU• Pupils: RAPD OD Pupils: RAPD OD • IOP: 4, 13IOP: 4, 13• External exam: right lid swellingExternal exam: right lid swelling• Slit lamp exam: wnl OSSlit lamp exam: wnl OS• Dilated fundus exam: nl N/M/V/P OSDilated fundus exam: nl N/M/V/P OS

















B scanB scan

Vitreous and subhyaloid opacitiesVitreous and subhyaloid opacitiesExtensive retinal detachmentExtensive retinal detachmentChoroidal detachmentChoroidal detachmentDiffuse thickening of the superior orbit Diffuse thickening of the superior orbit Thickening of the superior oblique insertionThickening of the superior oblique insertion



SummarySummary

• Nodular scleritis, keratitis, choroidal Nodular scleritis, keratitis, choroidal thickening, retinal detachmentthickening, retinal detachment

• Which tissue was primarily involved?Which tissue was primarily involved?



Probable ChronologyProbable Chronology

• Cellulitis/lid edemaCellulitis/lid edema

• KeratitisKeratitis

• Anterior nodular scleritisAnterior nodular scleritis

• Posterior scleritisPosterior scleritis

• Choroidal effusionChoroidal effusion

• Exudative retinal detachmentExudative retinal detachment



Etiology of Nodular ScleritisEtiology of Nodular Scleritis

• InfectiousInfectious• PseudomonasPseudomonas• StaphylococcusStaphylococcus• StreptococcusStreptococcus• Varicella zosterVaricella zoster• AcanthamoebaAcanthamoeba• ToxoplasmosisToxoplasmosis• MycobacteriaMycobacteria• Treponema pallidumTreponema pallidum• Borrelia burgdorferiBorrelia burgdorferi• Bartonella hensalaeBartonella hensalae• NocardiaNocardia• Proteus mirabilisProteus mirabilis• BrucellaBrucella• AspergillusAspergillus

• InflammatoryInflammatory• Connective tissue diseaseConnective tissue disease

RARA LupusLupus Seronegative Seronegative

spondyloarthropathiesspondyloarthropathies Relapsing polychondritisRelapsing polychondritis

• VasculitisVasculitis PANPAN Wegener’s granulomatosisWegener’s granulomatosis Giant cell arteritisGiant cell arteritis

• MetabolicMetabolic goutgout



Organisms that Penetrate intact Organisms that Penetrate intact CorneaCornea

• Corynebacterium diphtheriaeCorynebacterium diphtheriae

• NeisseriaNeisseria

• Haemophilus aegyptiusHaemophilus aegyptius

• Listeria monocytogenesListeria monocytogenes

• AcanthamoebaAcanthamoeba

• FungiFungi



Diagnostic StudiesDiagnostic Studies

• Smear of yellow Smear of yellow exudate from exudate from superonasal scleral superonasal scleral nodule nodule → PMNs, no → PMNs, no organismsorganisms

• Culture of biopsied of Culture of biopsied of nodule nodule → → • Pseudomonas Pseudomonas

aeruginosaaeruginosa



Pseudomonas aeruginosaPseudomonas aeruginosa

• Gram negative rodGram negative rod• Opportunistic pathogen Opportunistic pathogen • Fimbriae attach to sialic Fimbriae attach to sialic

acid receptors on acid receptors on epitheliumepithelium

• Elastase, alkaline Elastase, alkaline protease, exotoxin Aprotease, exotoxin A

• Rapidly destructive Rapidly destructive infectioninfection



ManagementManagement

• Fortified vancomycin and tobramycin Fortified vancomycin and tobramycin 1gtt of each Q1h OD1gtt of each Q1h OD

• Atropine 1gtt BID ODAtropine 1gtt BID OD

• Ciprofloxacin 500mg PO BIDCiprofloxacin 500mg PO BID



Pseudomonas scleritisPseudomonas scleritis

• Most common cause of infectious Most common cause of infectious scleritisscleritis

• Spreads under conjunctiva from corneaSpreads under conjunctiva from cornea

• Poor prognosisPoor prognosis• 60% of eyes with infectious keratoscleritis 60% of eyes with infectious keratoscleritis

were eviscerated, enucleated, or NLP.were eviscerated, enucleated, or NLP.



Predisposing factorsPredisposing factors

• Advanced ageAdvanced age• Poor healthPoor health• Ocular surface compromiseOcular surface compromise• Topical corticosteroidsTopical corticosteroids• Trauma/SurgeryTrauma/Surgery

• Pterygium excision with radiation/MMCPterygium excision with radiation/MMC• CEIOLCEIOL• Scleral bucklingScleral buckling• Strabismus surgeryStrabismus surgery



Rapid Spread of the OrganismRapid Spread of the Organism

• Penetrate into deep avascular collagen Penetrate into deep avascular collagen lamellae where there is poor scleral lamellae where there is poor scleral antibiotic penetrationantibiotic penetration

• Bacterial elaboration of collagenase and Bacterial elaboration of collagenase and proteolytic products that destroy ground proteolytic products that destroy ground substancesubstance

• Flagellation enables increased Flagellation enables increased organism motilityorganism motility



DiagnosisDiagnosis

• Corneal cultureCorneal culture

• Scleral biopsyScleral biopsy



HistopathologyHistopathology

• Ischemic necrosisIschemic necrosis• MicroabscessesMicroabscesses• PMNsPMNs• BacteriaBacteria

• Autoimmune scleritis does not cause Autoimmune scleritis does not cause microabscesses microabscesses



Secondary SequelaeSecondary Sequelae

• 3 reports of secondary exudative 3 reports of secondary exudative detachmentsdetachments

• 2 reports of well-documented posterior 2 reports of well-documented posterior scleritisscleritis



Exudative Retinal DetachmentExudative Retinal Detachment

• Retinal pigment Retinal pigment epithelium maintains epithelium maintains retinal adherence by retinal adherence by absorption of absorption of subretinal fluidsubretinal fluid• Active transportActive transport• Creation of an Creation of an

osmotic gradientosmotic gradient• Hydrostatic forcesHydrostatic forces



Exudative Retinal DetachmentExudative Retinal Detachment

• Choroiditis leads to Choroiditis leads to increased leakage from increased leakage from choroidal vesselschoroidal vessels

• RPE is overwhelmed by RPE is overwhelmed by excessive fluid leakage excessive fluid leakage from choroidfrom choroid

• Inflamed scleral fibers Inflamed scleral fibers provide increased provide increased resistance and resistance and decreased transscleral decreased transscleral outflowoutflow



Differential Diagnosis: Exudative Differential Diagnosis: Exudative Retinal DetachmentRetinal Detachment

• CongenitalCongenital• FEVRFEVR• NanophthalmosNanophthalmos

• PostsurgicalPostsurgical• UveitisUveitis

• Scleritis, neuroretinitisScleritis, neuroretinitis• InfectiousInfectious

• Syphilis, CMV, HZOSyphilis, CMV, HZO• VasculitisVasculitis• AutoimmuneAutoimmune

• VKHVKH• SOSO

• VascularVascular• HTNHTN• Toxemia of pregnancyToxemia of pregnancy• CRICRI

• HematologicHematologic• LeukemiaLeukemia

• NeoplasticNeoplastic• IdiopathicIdiopathic

• Idiopathic central serous Idiopathic central serous chorioretinopathychorioretinopathy

• Coats diseaseCoats disease• Uveal effusion syndromeUveal effusion syndrome



Pseudomonas EndophthalmitisPseudomonas Endophthalmitis

• Eifrig et al. 2003Eifrig et al. 2003• 28 patients28 patients• 7 patients had keratitis7 patients had keratitis• All NLP following interventionAll NLP following intervention

• 3 underwent vitreous tap3 underwent vitreous tap 1- ceftazidime1- ceftazidime 2 – vancomycin, ceftazidime, and dexamethasone2 – vancomycin, ceftazidime, and dexamethasone

• 43% – enucleated43% – enucleated• 57% - eviscerated57% - eviscerated



TreatmentTreatment

• Topical antibioticsTopical antibiotics

• Systemic antibioticsSystemic antibiotics

• Lavage therapyLavage therapy

• Surgical debridementSurgical debridement

• CryotherapyCryotherapy

• Corneoscleral graftingCorneoscleral grafting



Topical SystemicTopical Systemic

• FluoroquinolonesFluoroquinolones• Fortified Fortified

• GentamycinGentamycin• VancomycinVancomycin• AmikacinAmikacin• PiperacillinPiperacillin• TobramycinTobramycin• CefazolinCefazolin• TicarcillinTicarcillin

• BacitracinBacitracin• NeomycinNeomycin

• OralOral• CiprofloxacinCiprofloxacin

• IntravenousIntravenous• Helm et al. 1996Helm et al. 1996• 3 patients with 3 patients with

pseudomonas scleritispseudomonas scleritis• IV ceftazidime and IV ceftazidime and

aminoglycosidesaminoglycosides• 1-3 weeks of therapy1-3 weeks of therapy• VA 20/25 – 20/200VA 20/25 – 20/200• All globes salvagedAll globes salvaged



Subpalpebral lavageSubpalpebral lavage

• Meallet MA 2006Meallet MA 2006

• 6 patients with Pseudomonas 6 patients with Pseudomonas sclerokeratitissclerokeratitis

• 1 -2 weeks of lavage treatment1 -2 weeks of lavage treatment

• Pretx vision: LP – 20/200Pretx vision: LP – 20/200

• Posttx vision: HM – 20/40Posttx vision: HM – 20/40

• Eyes salvagedEyes salvaged



Subpalpebral lavageSubpalpebral lavage

• Tobramycin 100mg/mlTobramycin 100mg/ml• Levofloxacin 500mg/100mlLevofloxacin 500mg/100ml• 20ml/min20ml/min



Surgical debridementSurgical debridement

• Tseng SH 1998Tseng SH 1998• Pseudomonas sclerokeratitis refractory to Pseudomonas sclerokeratitis refractory to

medical therapymedical therapy• Associated exudative retinal detachmentAssociated exudative retinal detachment• Conjunctival dissection, debridement of Conjunctival dissection, debridement of

infectious scleral nodules, irrigation with infectious scleral nodules, irrigation with ceftazidimeceftazidime

• Absorption of subretinal fluid, resolution of Absorption of subretinal fluid, resolution of RDRD

• 20/200 20/200 → 20/40→ 20/40



CryotherapyCryotherapy

• Eiferman RA 1979Eiferman RA 1979• 2/3 patients Pseudomonas scleritis2/3 patients Pseudomonas scleritis• Intraoperative cryotherapy prior to Intraoperative cryotherapy prior to

penetrating keratoplastypenetrating keratoplasty• Resolution of infection/inflammationResolution of infection/inflammation• Mechanism of cell deathMechanism of cell death

• Osmotic shock: rapid dissolution of salts Osmotic shock: rapid dissolution of salts • Mechanical crushing of cellsMechanical crushing of cells



Back to our patientBack to our patient

• 3 weeks after presentation3 weeks after presentation

• VA HM VA HM

• IOP 13IOP 13

• Increasing size of infiltratesIncreasing size of infiltrates

• Pseudomonas growth from inferonasal Pseudomonas growth from inferonasal scleral infiltratescleral infiltrate



At presentationAt presentation

3 weeks later3 weeks later







Limbal peritomy and Limbal peritomy and incision and drainage incision and drainage



Post-op week 2Post-op week 2

• VA HMVA HM

• IOP 1IOP 1

• Decreased discharge, hyphema and Decreased discharge, hyphema and injectioninjection

• PF QID, Atropine BID, Gentamycin PF QID, Atropine BID, Gentamycin Q1h, PO CiprofloxacinQ1h, PO Ciprofloxacin

• Culture - negativeCulture - negative







2 weeks post-op2 weeks post-op



Pseudomonas scleritis: Pseudomonas scleritis: Take Home PointsTake Home Points

• Pseudomonas is the most common cause of Pseudomonas is the most common cause of infectious scleritis.infectious scleritis.

• Diagnosis can require scleral biopsy.Diagnosis can require scleral biopsy.• Long-term topical steroids is an important risk Long-term topical steroids is an important risk

factor.factor.• Always evaluate posterior segment in the Always evaluate posterior segment in the

setting of ocular inflammation.setting of ocular inflammation.• Systemic antibiotics should be administered Systemic antibiotics should be administered

in addition to topical therapy.in addition to topical therapy.• Pseudomonas scleritis can be a blinding Pseudomonas scleritis can be a blinding

condition.condition.

Documents

Bascom Palmer Eye Institute Grand Rounds Jaclyn Kovach, MD Discussants Janet Davis, MD Richard Forster, MD