Clinical Features and Treatment Outcomes in Patients with Infectious Scleritis

Mi-Hwa Park; Woong-Sun Yoo; Hyun-A Kim; Inyoung Chung; Seong-Wook Seo; Seong-Jae Kim

doi:10.3341/jkos.2019.60.6.510

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Park, Yoo, Kim, Chung, Seo, and Kim: Clinical Features and Treatment Outcomes in Patients with Infectious Scleritis

Original Article

J Korean Ophthalmol Soc 2019;60(6):510-518.

Published online: 25 September 2019

DOI: https://doi.org/10.3341/jkos.2019.60.6.510

Clinical Features and Treatment Outcomes in Patients with Infectious Scleritis

Mi-Hwa Park, MD^1,², Woong-Sun Yoo, MD^1,^2,³, Hyun-A Kim, MD^1,^2,³, Inyoung Chung, MD, PhD^1,^2,³, Seong-Wook Seo, MD, PhD^1,^2,³, Seong-Jae Kim, MD, PhD^1,^2,³

¹Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea

²Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea

³Health Science Institute, Gyeongsang National University, Jinju, Korea

Address reprint requests to Seong-Jae Kim, MD, PhD Department of Ophthalmology, Gyeongsang National University Hospital, #79 Gangnam-ro, Jinju 52727, Korea Tel: 82-55-750-8171, Fax: 82-55-758-4158 E-mail: maya12kim@naver.com

Received 31 January 2019 Revised 25 February 2019 Accepted 17 May 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To investigate risk factors, clinical features, pathogenic organisms, and outcomes in patients with infectious scleritis.

Results

The mean patient age was 69.2 ± 8.4 years and the mean duration of hospitalization was 11.3 ± 5.8 days. Furthermore, the mean duration of symptoms before presentation was 16.8 ± 13.9 days; patients were followed for a mean duration of 23.3 ±25.4 months. All patients had prior pterygium surgery. Eighteen patients (90%) were culture-positive and Pseudomonas aeruginosa (P. aeruginosa) was identified in 12 eyes. In the acute stages, adjuvant surgical intervention was performed for 18 patients (90%) for these patients, the mean duration of hospitalization before surgery was 4.1 ± 4.4 days.

Methods

This study was a retrospective review of 20 patients with infectious scleritis who were admitted from January 2011 to December 2018 in a single tertiary hospital, with at least 3 months of follow-up. We analyzed age, risk factors, clinical manifestations, pathogenic organisms, treatment, and outcomes of infectious scleritis.

Conclusions

The most common risk factor and pathogenic organism for infectious scleritis were prior pterygium surgery and P. aeruginosa, respectively. Identification of specific causative organisms and corresponding antibiotic treatment with adjuvant surgical intervention may improve visual prognosis in patients with infectious scleritis.

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Keywords: Eye infections, Pseudomonas aeruginosa, Scleritis

References

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Figure 1.

Anterior segment photograph of patient with infectious scleritis before (A) and after (B) treatment. (A) Infectious scleritis caused by Pseudomonas aeruginosa developed at the previous pterygium excision area that presented with scleral necrosis. (B) Scleritis was resolved after treatment with intensive antibiotics and perichondrium graft with conjunctival flap.

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Figure 2.

Slit lamp photograph depicting Aspergillus flavus scleritis in a patient 10 years after pterygium surgery. (A) At the presentation showing scleral melting and abscess formation. (B) Fungus ball-like lesion were detected in the anterior chamber angle.

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Figure 3.

Anterior segment photo of a patient with infections scleritis. Seventy-year-old woman with fungal (Fusarium species) scleritis after pterygium excision. There was a severe scleral necrosis and adjacent corneal infiltration with satellite lesions.

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Table 1.

Demographics of patients with infectious scleritis

Demographics of patients with infectious scleritis	Value
Age (years)	69.2 ± 8.4 (51–81)
Sex
Male	4 (15)
Female	16 (80)
Laterality (right/left)	10/10
Mean best corrected visual acuity (Snellen acuity)
Initial	0.3 ± 0.3
Final	0.6 ± 0.3
Mean intraocular pressure (mmHg)
Initial	14.0 ± 3.9
Final	11.7 ± 3.3
Mean hospitalization duration (days)	11.3 ± 5.8 (2–23)
Mean symptom duration (days)	16.8 ± 13.9 (2–23)
Mean follow up duration (months)	23.3 ± 25.4 (4–84)
Predisposing factor
Pterygium surgery	20 (100)
Mean time from pterygium surgery to infection (years)	8.7 ± 5.6 (1–20)

Values are presented as mean ± standard deviation (range) or number (%).

Table 2.

Clinical characteristics of patients with infectious scleritis

Clinical characteristics of patients with infectious scleritis	Value
Route of admission
Emergency department	3 (15)
Outpatient department	17 (85)
Initial presentation features
Scleral necrosis	20 (100)
Median area of necrosis (clock hours)	2.8 ± 1.1 (1–5)
Multifocal scleral abscesses	8 (40)
Calcified plaque	18 (90)
Anterior segment inflammation	14 (70)
Hypopyon	4 (20)
Corneal involvement	3 (15)
Orbital/preseptal cellulitis	1 (5)
Laboratory results
ESR (mm/hours)	44.9 ± 27.6 (0–9)
CRP (mg/L)	11.9 ± 19.9 (0–5)
Uric acid (mg/dL)	3.7 ± 1.4 (3.4–7.0)
RF positivity (person)	5 (25)
ANA positivity (person)	8 (40)
Treatment before infectious scleritis diagnosis
Steroid	13 (65)
Topical corticosteroid	11 (55)
Systemic corticosteroid	6 (30)
Antibiotics	7 (35)

Values are presented as mean ± standard deviation (range) or number (%).

ESR = erythrocyte sedimentation rate; CRP = C-reactive protein; RF = rheumatoid factor; ANA = antinuclear antibody.

Table 3.

Culture results in patients with infectious scleritis

Culture results in patients with infectio scleritisus	Value
Type of organisms
Bacteria	14 (70)
Fungi	3 (15)
Mixed	1 (5)
Culture negative	2 (10)
Isolated Pathogens
Bacteria
P. aeruginosa	12 (60)
Serratia marcescens	1 (5)
S. aureus	1 (5)
Enterococcus faecium	1 (5)
Fungi
Aspergillus flavus	1 (5)
Candida albicans	2 (10)
Fusarium species	1 (5)

Values are presented as number (%).

Table 4.

Medical and surgical treatment in patients with infectious scleritis

Medical and surgical treatment in patients with infectious scleritis	Value
Medical treatment	20 (100)
Intravenous antimicrobials	17 (85)
Ciprofloxacin	11 (55)
Ceftazidime	15 (75)
Fluconazole	2 (10)
Topical antimicrobials	20 (100)
Levofloxacin	5 (25)
Moxifloxacin	14 (70)
Fortified ceftazidime	15 (75)
Vancomycin	2 (10)
Fluconazole	4 (20)
Amphotericin B	4 (20)
Natamycin	2 (10)
Voriconazole	2 (10)
Adjuvant steroid treatment	9 (45)
Mean time from admission to steroid treatment (days)	7.3 ± 4.4 (3–16)
Mean doses (mg/day)	25.6 ± 6.8 (20–40)
Surgical treatment	18 (90)
Mean duration from admission to surgical interventions (days)	4.1 ± 4.4 (1–20)
Surgical debridement	1 (5)
Conjunctival flap	3 (15)
Scleral graft with conjunctival flap	4 (20)
Perichondirium graft with conjunctival flap	10 (50)

Values are presented as mean ± standard deviation (range) or number (%).

Table 5.

Complications during treatment

Complications during treatment	Value
Retinal detachment	1 (5)
Choroidal detachment	5 (25)
Medial gaze limitation	3 (15)
Scleral thinning	2 (10)
Endophthalmitis	2 (10)
Ocular hypertension/glaucoma	1 (5)
Corneal opacity	1 (5)

Values are presented as number (%).

Table 6.

Univariate analysis evaluating the risk factors for poor visual outcome (BCVA < 0.3) in patients with infectious scleritis

Factor	OR (95% CI)	p-value^*
Age	1.014 (1.000–1.029)	0.05
Gender (female)	0.080 (0.000–1.472)	0.09
Latency period	1.063 (0.967–1.168)	0.21
Duration of symptoms before admission	1.033 (0.984–1.085)	0.19
Route of admission (OPD)	1.250 (0.971–1.610)	0.30
Duration of hospitalization	1.070 (0.987–1.160)	0.07
Previous steroid treatment	0.750 (0.055–2.886)	0.71
Area of necrotic scleritis involvement	1.355 (0.960–1.911)	0.13
Presented BCVA (< 0.3)	1.667 (1.103–2.519)	0.10
Anterior segment inflammation	0.500 (0.166–1.506)	0.13
Calcified plaque	0.857 (0.542–1.356)	0.45
Corneal involvement	1.500 (0.170–13.255)	0.60
Hypopyon	1.000 (0.132–7.570	0.72
ESR	1.100 (0.990–1.230)	0.18
Culture positivity of bacteria	2.580 (0.070–9.340)	0.61
Adjuvant steroid treatment	0.440 (0.040–5.110)	0.51
Perichondrium graft	0.320 (0.030–3.780)	0.36
Retinal/choroidal detachment	0.750 (0.107–5.238)	0.63
Scleral thinning	0.429 (0.032–5.779)	0.52
Endophthalmitis	0.857 (0.692–1.062)	0.48

BCVA = best corrected visual acuity; OR = odds ratio; CI = con-fidential interval; OPD = outpatient department; ESR = erythrocyte sedimentation rate.

^* p-value was calculated by univariate logistic regression analysis.

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