A clinical case of surgical treatment of severe Nocardia keratitis in a contact lens wearer.

Abstract

Nocardia is an aerobic, weakly acid-fast bacterium of the Actinomycete genus that rarely causes eye diseases, of which corneal infection is the most common. Purpose: To present a clinical case of successful surgical treatment of severe keratitis caused by Nocardia strain. Methods: Patient complained of redness, pain, tearing, decreased visual acuity of right eye. The patient is a contact lenses wearer due to high myopia. 3 weeks ago, while opening the new contact lens, she noticed that the box was damaged and partially open, but still put a lens on her eye. The same day the redness of the eye appeared. A diagnosis of keratitis was made and antibacterial, non-steroidal anti-infammatory drops were prescribed, as well as parabulbar injections of dexamethasone and de-epithelialization of the cornea was performed with the subsequent implantation of bandage contact lens. Upon admission to the hospital–the conjunctiva was hyperemic, ulcer in the center of the cornea with edema and stroma infltration. BCVA ОD = 0,03 BCVA ОS = 0,85. The patient was diagnosed with stromal keratitis of mixed etiology after wearing contact lenses of right eye. Results: Prescribed treatment included instillation of chlorhexidine, fuconazole, voriconazole, mydriatics; per os valacyclovir, itraconazole. In 10 days increased corneal stroma infltration and the appearance of recurrent hypopyon were observed. Intravenous injections of ornidazole, fuconazole, levofoxacin were added to the treatment. Due to increased hypopyon level anterior chamber washout with fuconazole solution was performed with following microbiological examination with Nocardia spp detection. Fortifed instillations of vancomycin 50 mg/ml and clarithromycin per os were added to the treatment. Due to the large area of corneal damage, a therapeutic keratoplasty was performed on the right eye. A day before the operation, due to hypopyon recurrence, repeated anterior chamber washout with vancomycin solution was performed. Upon discharge from the hospital–the transparent corneal graft was well adapted with interrupted sutures with epithelialized surface. BCVA OD was 0.05. Conclusions: It was the etiotropic therapy with antibiotics sensitive to the identifed strain of Nocardia together with therapeutic keratoplasty that made it possible to control the infammatory process, save the eye and restore the patient’s sight.