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When a tiny Sand Particle caused havoc!

Severe pain, redness, watering and blurring of vision in his right eye since 10 days brought Mr. Krishnan Nair, aged 31, to Dr. Vandana Jain. He vaguely remembered sand particles having fallen into his right eye a month ago. He did not have any systemic illness.

Mr. Krishnan’s eye sight was tested. While his distance and near vision was normal in his left eye, the vision in his right eye was so poor that he could not accurately perceive the presence of a light even 10 cm from his right eye (inaccurate projection of rays). Dr Jain examined his eyes and found that his lids showed marked edema (swelling).

 

Nocardia Bacteria 

 

There was a well-defined, dirty white, raised lesion at the border of the cornea with the sclera (called the limbus) measuring 2.5 x 2.5 mm and was painful to touch. Examination showed that the lesion had spread into his cornea (mid-stromal infiltrate 3-mm inside the limbus). The surrounding cornea showed swelling (stromal edema with folds in the Descemet’s membrane). B-Scan ultrasonography revealed an echo-free vitreous cavity with attached retina.

Based on the presence of severe pain, a tender nodular scleral lesion, and dirty-yellow granular exudates in the anterior chamber, Dr Jain diagnosed the patient as a case of scleritis (inflammation of the sclera) with corneal ulcer of caused by infection. Microbiology work-up of scraping from the lesion showed that it was infected with bacteria. (gram-positive bacilli and Nocardia asteroids). All other systemic examination and HIV blood tests were normal. Based on the smear results, treatment was started (Antibiotics for two months followed by steroid drops). Six weeks later the lesion had resolved and the best-corrected visual acuity in the right eye was 20/60.

 

Take Home Message:

  • Infectious scleritis is a devastating eye disorder, which may follow accidental or surgical injury or a spread from adjoining corneal infection. Microorganisms enter the sclera either during initial surgery or at a later stage due to absence of normal conjunctival re-growth and associated tear film alterations. Thus these organisms localize, adhere, colonize and then invade the tissues.
  • Nocardia, as an offending organism causing infective scleritis is extremely rare. Nocardia infections are usually characterized by a previous history of injury or surgery and run a slow chronic clinical course.
  • Steroids are known to worsen the infection. Occasionally, Nocardia may cause scleritis in young healthy individuals even in the absence of predisposing factors. The organisms can even extend to the anterior chamber.  A high degree of clinical suspicion and intensive microbiological work-up will result in prompt diagnosis and initiation of appropriate therapy. Outcome of the disease with intensive medical therapy and surgical debridement may be satisfactory.

 

(Not his real name)