Occult Fungal Scleritis

Abstract

Purpose: To heighten awareness of occult fungal scleritis.

Method: Case report and review of the literature.

Results: A 73-year-old woman with diabetes mellitus was diagnosed for 3 months with immune-mediated scleritis and subsequently treated with corticosteroids. On referral, the patient had a scleral nodule with contiguous corneal infiltrate and hypopyon. Culture grew Fusarium species not further classified. The infection could not be controlled with antifungal therapy, and the eye was removed. No exogenous or endogenous source for the infection could be identified by clinical history or examination.

Conclusion: Fungal scleritis can develop in persons without a history of foreign body injury, minor trauma, or evidence of endogenous fungemia. A high index of suspicion for infectious scleritis must be maintained in persons with presumed immune-mediated scleritis who fail to respond to conventional therapy, particularly if they present with decreased visual acuity.

Keywords: Fusarium scleritis; Infectious scleritis; Subtenon triamcinolone acetonide.

Fig. 1

A nonulcerated peripheral corneal infiltrate is adjacent to the scleral nodule. The entire sector of conjunctiva is inflamed. A hypopyon is seen inferiorly in the anterior chamber. Inset Anterior segment optic coherence tomography shows hyperreflectivity of the stroma and endothelium. The scleral nodule is noted immediately posterior to the limbus.

Fig. 2

The enucleated eye shows severe scleral thinning (arrow) at the clinical nodule. The lens was dislocated during sectioning. Scleral inflammation and necrosis extends past the equator of globe. The orbital connective tissue contiguous to the inflamed sclera was infiltrated by lymphocytes and histiocytes, and fewer numbers of neutrophils (hematoxylin-eosin, scale bar = 2.75 mm).

Fig. 3

Periodic acid-Schiff stain reveals numerous fungal hyphae within the layers of the cornea. Descemet's membrane has been detached. Purulent exudate fills the anterior chamber and the space between Descemet's membrane and the stroma (scale bar = 170 μm). Inset Magnified view of the same area with a closer view of the fungal hyphae in the cornea and the confluent neutrophils within the anterior chamber (scale bar = 75 μm). DM = Descemet's membrane.

Fig. 4

High-magnification view of the sclera marked with an arrow in figure 2 shows septate fungal hyphae at the junction of necrotic tissue above and scleral collagen below (scale bar = 75 μm).