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      Over-Treated Corneal Abscess May Be Toxic Keratopathy

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          Abstract

          Background/Aims

          Keratitis, especially when long-standing and unresponsive to common antimicrobial treatment, leads to a suspicion of fungal aetiology.

          Methods

          Photographically documented case report.

          Results

          A 65-year-old man with diabetes was referred for corneal abscess unresponsive to antibiotic and antifungal treatment lasting 6 weeks. Corneal biopsy was performed following a 72-hour washout for identification of bacteria and fungi. Previously administered drops were withdrawn and only preservative-free artificial tears were maintained. Neither bacteria nor fungi were cultured. After 2 weeks, the clinical situation had conspicuously improved.

          Conclusion

          Over-treatment of corneal affections fearing mycosis may lead to toxic keratopathy.

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          Most cited references 5

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          Evaluation of intrastromal injection of voriconazole as a therapeutic adjunctive for the management of deep recalcitrant fungal keratitis.

          To evaluate the role of intrastromal injection of voriconazole in the management of deep recalcitrant fungal keratitis. Interventional case series. Cornea services at a tertiary care teaching hospital. Three eyes of three patients with deep stromal recalcitrant fungal keratitis not responding to topical antifungal medications. Intervention Procedure: Voriconazole 50 micrograms/0.1 ml was injected circumferentially around the fungal abscess in the corneal stroma as an adjunctive to the topical antifungal therapy. Main outcome measure was a reduction in size of the abscess and resolution of the infection. Before the intracorneal injection, all three eyes had gradually worsening lesions on topical medications. After the intervention, a faster reduction in the size of corneal infiltration was documented and a complete resolution of the ulcers was seen within three weeks in all cases. Targeted delivery of voriconazole by intracorneal injection may be a safe and effective way to treat cases of deep-seated recalcitrant fungal keratitis responding poorly to conventional treatment modalities.
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            Corneal toxicity: the epithelium and stroma in iatrogenic and factitious disease.

             Andrew Dart (2003)
            Corneal toxicity is caused by chemical trauma and by iatrogenic and factitious disease, which are often overlooked, and which are reviewed here. The clinical signs of iatrogenic disease are usually nonspecific and identical to those resulting from other causes of surface disease. Factitious disease is either the result of mechanical trauma or the abuse of toxic eye drops. One epidemiological study, in a tertiary setting, identified 13% of keratoconjunctivitis cases as iatrogenic. Healing was prolonged taking 7-93 (median 28.5) days. Pathogenic mechanisms vary widely with different drugs and include subclinical scarring, pseudopemphigoid, drug-induced ocular cicatricial pemphigoid, and toxic follicular reactions. There is little readily available data either on the probability of the development of adverse reactions or for the comparison of different drugs. The assessment of the toxicity of topical drugs is currently by the Draize test in rabbits. New in vitro tests on human corneal epithelial cell cultures include ATP assays for cell viability, scanning EM of epithelial microvilli, and vital staining to assess cell membrane permeability and intracellular esterase. Despite their simplicity, these test systems can correlate well with clinical toxicity and provide a toxicity index for drug comparisons. Treatment requires drug withdrawal or substitution by non-preserved and less toxic preparations. Factitious injury is rare, difficult to diagnose, and should only be considered when all other diagnoses have been excluded. Prevention requires a high level of awareness of the potential for iatrogenic disease, particularly in the high-risk setting of chronic ocular surface disease.
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              Adverse external ocular effects of topical ophthalmic therapy: an epidemiologic, laboratory, and clinical study.

              New knowledge of adverse external ocular reactions to topical ophthalmic medications was obtained by means of a computerized epidemiologic study, laboratory studies, and clinical observations. Listed below are the major findings and conclusions that represent facts or concepts that were previously unknown, uncertain, misunderstood, or forgotten: The incidence of clinically important drug reactions among all cases was at least 13.09% and may have been as high as 16.02%. Among treated patients it was at least 16.26% to 19.90%. Taken together, drug reactions were the second most common external disease diagnosis. The incidence of each kind of drug reaction was determined. Toxic papillary reactions accounted for 79.10% of drug cases and 10.35% of all cases. Toxic papillary keratoconjunctivitis was the third most common single diagnosis. The following epidemiologic factors were found to be related to the development or presence of drug reactions: number and variety of treating practitioners, number of practitioners consulted, number of practitioners consulted who treated, specific ophthalmologist consulted (8.24% of ophthalmologists referred 39.55% of all drug cases and showed a tendency habitually to overtreat), number and kinds of patients' symptomatic complaints, number of medications prescribed and used, number of days of treatment, particular drugs and preservatives used (but not their strengths or vehicles), underlying (primary) diagnoses, and inaccuracy of referring ophthalmologists' diagnoses. Patients with dry eyes were especially at risk for the development of toxic papillary reactions. Among all cases, the incidence of reactions to preservatives (mainly thimerosal) in contact lens solutions was 0.39% to 1.95%, depending on whether definite or probable cases, respectively, were considered. The incidence among the 54 patients who used daily-wear lenses (excluding extended-wear therapeutic and optical contacts) was 7.41% for definite reactions and 37.04% for probable ones. Factors relating to the development of papillary contact-lens reactions were daily wear, number of days of wear, and, especially, the preservatives to which the patients were exposed. Reactions occurred more often with soft lenses than with hard ones. Of patients with drug reactions, 5.22% had two different ones simultaneously. Coexisting reactions to pharmacologically active agents were also present in 15% of patients who reacted to preservatives in contact lens solutions. The ocular tissues that were affected by each kind of drug reaction were tabulated, and the relative degrees and sequences of involvement were discussed. The frequencies with which particular drugs, physical ag
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                Author and article information

                Journal
                Case Report Ophthalmol
                COP
                Case Reports in Ophthalmology
                S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.ch )
                1663-2699
                May-Aug 2010
                11 June 2010
                11 June 2010
                : 1
                : 1
                : 20-23
                Affiliations
                Institute of Ophthalmology, University of Parma, Parma, Italy
                Author notes
                *Paolo Mora, MD, Institute of Ophthalmology, University of Parma, via Gramsci 14, IT–43100 Parma (Italy), Tel. +39 0521 703 138, Fax +39 0521 992 137, E-Mail paolo.mora@ 123456unipr.it
                Article
                cop0001-0020
                10.1159/000315397
                2914444
                20737055
                Copyright © 2010 by S. Karger AG, Basel

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial-No-Derivative-Works License ( http://creativecommons.org/licenses/by-nc-nd/3.0/). Users may download, print and share this work on the Internet for noncommercial purposes only, provided the original work is properly cited, and a link to the original work on http://www.karger.com and the terms of this license are included in any shared versions.

                Page count
                Figures: 2, References: 5, Pages: 4
                Categories
                Published: June 2010

                Ophthalmology & Optometry

                toxic keratopathy, corneal abscess, corneal mycosis

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