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Posters

Surgical management of culture-proven non-keratitic nocardia infection

Poster Details

First Author: P.Susvar INDIA

Co Author(s):    L. Therese   G. Ramasubban   B. Srinivasan   G. Lingam         0   0 0   0 0   0 0   0 0

Abstract Details



Purpose:

Medical management with the topical amikacin conventional antibiotic has been the primary modality of treatment in Nocordia infections of the eye. Predilection to the cornea by the organism is common compared to other tissue involvement such as dacrocystitis, scleritis, episcleral granuloma and endophthalmitis. These conditions require more aggressive and radical surgical treatment to eradicate this smouldering infection. Purpose of this poster is to familiarize five such unusual and varied presentation of nocordia ocular infection. The objective is also to highlight the importance of the high index of suspicion in the diagnosis and aggressive surgical treatment in clearing these infections .

Setting:

Medical Research Foundation, tertiary referral eye care centre

Methods:

Consecutive case series of surgical management of five cases of culture-proven non keratitic nocardia infection undergoing anterior and posterior segment surgeries

Results:

First patient of the series developed subconjuctival abscess following cataract surgery. Initial subconjuctival (SC) aspirates were microbioloically negative, repeated subconjuntival wash samples revealed nocardia species on staining and in culture. Eye was salvaged with amikacin SC injections with surgical wash. Second patient presented as viral retinitis, treated accordingly. With worsening subretinal exudation and vitrectomy, subretinal fluid on culture showed nocardia, eye could not be salvaged. Third case started as decreased vision in left eye with hypopyon and vitritis; AC tap was negative. Despite intravitreal antibiotics, condition worsened, vitrectomy sample was negative again on culture. Condition worsened to panophthalmitis, underwent evisceration. Sample revealed nocardia species. Five months later, developed socket infection with nocardia and had wound debridement. Fourth case had exposed buckle suture knot, with conjunctival swab negative. With worsening , scleral buckle removal material grew nocardia. With recurrent retinal detachment (RD) , vitrectomy and then oil removal, four year follow up, had no evidence of infection, vision stabilised. Last case of the series had keratoprosthesis with RD surgery performed twice. Four years later, during RD surgery, endophthalmitis was noted and vitreous sample revealed nocardia on culture, however eye could not be salvaged.

Conclusions:

Nocardia ocular infection can have unusual presentation showing opportunistic and smoldering nature. Clinical recognition of nocardia is difficult because of the lack of pathognomic symptoms. Repeated sampling of various ocular tissues during any surgical procedures at specific tissue levels will be needed to identify the nocordia organism in such cases. Orbital and scleral infections require more aggressive surgical treatment and debridement. Scleral involvement has a better anatomical and visual prognosis, compared to vitreous involvement. Organisms are still responsive to routine antibiotics- amikacin and cotrimoxazole. One needs to have high suspicion of nocardia infection in atypical cases not responding to routine conventional antibiotics.

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