Keratoplasty in contact lens related Nocardia Keratouveitis

Abstract

Introduction: Keratitis due to Nocardia infection is not commonly encountered in clinical practice and may be mistaken for fungal or viral keratitis. Late diagnosis may lead to a prolonged recovery and visual impairment. Purpose: To report a case of Nocardia keratouveitis in a contact lens wearer undergoing keratoplasty. Methods: A 63-year-old lady presented with complaints of pain, redness, low vision and watering from the right eye. Two months before she put on a damaged contaminated lens and all this time received unsuccessful treatment. Slit lamp examination revealed mixed conjunctival injection, limbal vascularization, corneal erosion, patchy stromal infiltrates with satellite lesions (one large central infiltrate surrounded by multiple small yellow pinhead-sized ones), 3.0 mm hypopyon. IOP was increased, BCVA 0.03. Results: Against the background of intensive antifungal and antibacterial therapy, the intensification and spread of infiltration was noted as well as the recurrent nature of hypopyon. The patient underwent anterior chamber washout with a solution of Voriconazole 100 mg/0.1 ml and its contents were taken for microbiological examination. By microscopy and culture, it was identified Nocardia spp, sensitive to Vancomycin. The patient was prescribed a course of forced instillations of Vancomycin hourly, while continuing to take Voriconazole instillations and Itraconazole per os. The day before keratoplasty, the patient underwent repeated anterior chamber washout with a solution of Vancomycin 1 mg/0.1 ml with its simultaneous intrastromal corneal injections. The patient underwent therapeutic penetrating keratoplasty d = 8.0/8.75 mm with intraoperative anterior chamber washout with Vancomycin solution. At the time of discharge, the corneal graft was transparent and well adapted, the IOP was normalized under drops. BCVA 0.05. The patient continued Vancomycin instillations for 1 month. There were no recurrences of Nocardia keratitis and after 8 months the patient underwent cataract phacoemulsification surgery. BCVA after the operation was 0.5. Conclusions: Nocardia keratitis should be considered in the differential diagnosis of contact lens related keratitis. Thanks to the results of microbiological culture studies, the forced Vancomycin instillations with per os Itraconazole combination, repeated anterior chamber washouts, as well as timely therapeutic keratoplasty, it was possible to eliminate the infection, and save high visual functions.