44-year-old male soft contact lens wearer presented with six-day history of 10/10 eye pain, decreased VA left eye, green discharge and redness
He was seen at an outside eye clinic one day after onset of symptoms and started on moxifloxacin (Vigamox) and gentamicin every one hour alternating
Five days later presented to LAC+USC Medical Center with pain significantly improved to 5/10
VAcc: 20/40, hand motion
Pupils: round & reactive, opacified cornea
IOP: 14, 20
EOM: Full OU
funds exam left eye: No view
HSV necrotizing keratitis
B scan: trace vitreous opacities, retina attached
Central involving corneal ulcer likely secondary to Pseudomonas Aeruginosa
With the determination of normal ICP, it was concluded that the optic neuropathy was most likely related to infiltration and inflammation of the optic nerves secondary to worsening cryptococcal infection rather than the more commonly seen scenario of papilledema secondary to elevated ICP from cryptococcal meningitis. It is estimated that approximately 75% of patients with cryptococcal meningitis will develop elevation of ICP (often severe) thought to result from the depositing of proteins and inflammatory by-products along the arachnoid granulations. This impairs absorption of CSF. In our case, the hypothesis of worsening cryptococcal infection was supported by the observed increase in enhancing cystic lesions on follow-up brain MRI. There is also likely a component of IRIS given the patient’s history of cryptococcal infection and re-initiation of HAART 3 months prior. The worsening parenchymal edema on MRI is consistent with this heightened inflammatory response.
Vancomycin 50mg/ml and tobramycin 14mg/ml every one hour alternating were initiated
Vitamin C 500mg daily and doxycycline 100mg BID were added given central corneal thinning
Fortified vancomycin and tobramycin were gradually tapered to Q4H as pain improved and epithelial defect resolved. Vancomycin was then discontinued and tobramycin QID was kept for an additional week prior to discontinuing
One month visit: Dense stromal scar with no epi defect. Tobramycin QID was then discontinued
Prognosis and Future Directions
Visual prognosis is poor given central stromal scar. Patient was able to count fingers only in periphery at one month visit.
Role of steroids in improving VA by decreasing stromal scar is controversial. Studies have shown that steroids can be detrimental in Acanthamoeba, Nocardia and fungal related corneal ulcers. For other bacteria, the risk of steroids is lower and may have some benefit. However, most patients with large central involving ulcers will ultimately require a corneal transplant.
Role of corticosteroids and other therapeutic interventions such as amniotic membrane grafts and possibly cornea cross-linking need to be further evaluated.
McLeodSD, Kolahdouz-IsfahaniA, RostamianK, FlowersCW, Lee PP, McDonnell PJ. The role of smears, cultures and antibiotic sensitivity testing in the management of suspected infectious keratitis. Ophthalmology 1996;103(1):23-28.
Rodman RC, Spisak S, Sugar A, Meyer RF, Soong HK, Musch DC. The utility of culturing corneal ulcers in a tertiary referral center versus a general ophthalmology clinic. Ophthalmology 1997;104(11):1897-1901.
McDonnell PJ, Nobe J, Gauderman WJ, et al. Community care of corneal ulcers. Am J Ophthalmol 1992;114:531-8.
Tallab RT, Stone DU. Corticosteroids as a therapy for bacterial keratitis: an evidence-based review of ‘who, when and why.’ BR J Ophthalmlol 2016;100:731-5.
Srinivasan M, Mascarenhas J, Rajaraman R, et al. The steroids for corneal ulcers trial (SCUT): secondary 12-month clinical outcomes of a randomized controlled trial. Am J Ophthalmol. 2014;157(2):327-333.e3.
Lalitha P, Srinivasan M, Rajaraman R, et al. Nocardia keratitis: clinical course and effect of corticosteroids. Am J Ophthalmol. 2012;154(6):934-939.e1.