Nocardia scleritis—clinical presentation and management: a report of three cases and review of literature
© The Author(s) 2011
Received: 28 May 2011
Accepted: 22 September 2011
Published: 8 October 2011
This study aims to describe the clinical features and management of Nocardia scleritis.
The authors retrospectively reviewed medical charts of three patients with microbiologically proven Nocardia scleritis and reviewed literature.
All the patients presented with areas of well-demarcated, circumscribed abscess. No specific clinical feature could be attributed to the causative organism. Nocardia was identified by smear and culture from the scleral exudates. The medical management was based on the antibiotic sensitivity. Surgical exploration of the suppurated area along with the healthy margins was done on all patients. Two patients required multiple explorations. All three patients resolved with a good visual and tectonic outcome. The literature review also suggests a good outcome with prolonged medical management though the preferred antibiotic has changed over the years.
Though the prevalence of a disease like Nocardia scleritis is low, the results suggest that specific diagnosis and appropriate management can lead to a good outcome.
Isolated Nocardia scleritis is rare, and usually occurs due to an extension of corneal infection involving the limbus . The available literature is mostly a collection of case reports [2–11]. It is difficult to diagnose due to its rarity. A delay in diagnosis and specific treatment can lead to potential sight-threatening complications. Intraocular extension of Nocardial scleritis has been reported . Although there are several reports on Nocardia keratitis and sclerokeratitis in the literature (Pubmed), there are few published data on isolated Nocardia scleritis [12, 13]. We report the clinical presentation and management of three cases of isolated scleritis due to Nocardia spp. We have also reviewed all the cases published till date.
Clinical summary, management, and outcome of all reported cases of isilated Nocardia scleritis
Duration of symptoms
Scleral buckle, cataract surgery
Topical and TMP-SMX (iv)
Scleral buckle, cataract surgery
Topical 10% sulphacetamide, TMP-SMX (iv)
Topical amikacin, topical and oral TMP-SMX
Surgical debridement, scleral patch graft
Injury with vegetable material, steroids
Cefazolin (systemic and topical)
Explantation of exposed buckle, steroids
Topical amikacin 2.5%, TMP-SMX 160/800
Cefazolin (systemic and topical), TMP-SMX 160/800, 10% sulphacetamide
Worsened and lost to follow up
Mud splash, steroids
Topical TMP-SMX 160/800, amikacin 2.5%, amoxycillin/clavulanate (800/125 mg)
CF 1 m
Topical trimetho prim/polymixin B, minocycline 100 mg/day
Scleral exploration and biopsy and bovine pericardium patch graft
60.66 ± 7.36
Scleral buckle—n = 2
Topical amikacin—all cases, TMP-SMX 160/800—n = 2
Debridement n = 1
56.8 ± 13
Injury with organic material—n = 5
30.4 ± 16.8 days
Topical amikacin/ciprofloxacin/cefazolin—n = 11
Surgical debridement—n = 8; conjunctival excision—n = 2; tissue adhesive—n = 1
Scleral buckle—n = 1
Systemic amikacin—n = 3
PPV—n = 1
Topical tobramycin, moxifloxacin, oral TMP-SMX
A 55-year-old lady presented with a history of pain and redness in the left eye for 2 months. She was on oral prednisolone (1 mg/kg body weight), and topical chloramphenicol-dexamethasone for the last 2 months. Her vision in the left eye was 20/200. Slit lamp examination of the left eye showed a circumscribed abscess in the superior bulbar area and cataract. Scleral exudates showed thin acid fast branching filaments under microscope and culture revealed Nocardia asteroides (identified based on biochemical tests). She was initiated on topical amikacin 2.5% and ciprofloxacin 0.3% every hour and oral ciprofloxacin 500 mg twice daily. The sclera was explored twice because of recurrence in the inferotemporal quadrant. Postoperatively she was advised topical amikacin 2.5% and gatifloxacin 0.3% every hour along with systemic gatifloxacin 400 mg once daily. At 3 months follow-up the corrected visual acuity at 20/50; there was cataract, though the sclera was thinned and there was uveal show.
The conjunctiva overlying the suppurated area was excised. The suppurated material along with necrotic sclera was removed. These were sent for a microbiology evaluation. Care was taken to clean the margin as far as possible to obtain a healthy sclera. The base and margin were irrigated thoroughly. Postoperatively subconjunctival amikacin was injected to the surrounding conjunctiva. At the end of surgery the conjunctiva was not closed. This helps in the penetration of the topical medication
The scleral scrapings/exudates were subjected to microscopic examination (Gram stain, modified Zeihl Neelsen stain using 1% H2SO4) and culture on sheep blood agar, chocolate agar, brain heart infusion broth, thioglycollate broth, and Sabouraud dextrose agar. Microscopic examination of the scleral exudates showed acid fast thin, beaded, branching filaments in all patients. In all cases, slow growing, chalky white dry colonies grew on blood and chocolate agar. Based on biochemical tests such as urease production, hydrolysis of casein, xanthine, tyrosin, and growth in gelatine, one of the isolates was identified as N. asteroids. (The susceptibility of the isolates was tested on Muller Hinton blood agar by disk diffusion method).
In vitro antibiotic susceptibility (by Kirby Bauer disk diffusion technique)
The lesions in 17 out of 23 patients had resolved with treatment. Topical amikacin 2.5%, TMP-SMX, cefazolin, sulphacetamide10%, and systemic TMP-SMX were the most common medication used. In vitro antibiotic sensitivity (by Kirby Bauer disk diffusion technique) of our patients is compiled in Table 1. The organisms were susceptible to amikacin and gatifloxacin in all cases whereas the organisms were resistant to cefazolin in two of the three cases. These findings are in concordance with DeCroos et al.  who describe maximum sensitivity to amikacin and gatifloxacin and minimal sensitivity to cefazolin. Intensive topical amikacin 2.5% along with a flouroquinolone was used for treatment in all our cases. Oral TMP-SMX was advised in one case and flouroquinolones in two cases. Sclera being an avascular structure, the bioavailability of systemic antibiotics is poor, therefore, the period of systemic antibiotic was prolonged from 4–8 weeks.
Out of 21 of the published cases who recovered, 17 needed surgical intervention. In the series described by DeCroos et al. , four of the 11 required multiple interventions. All three of our patients were debrided and exudative materials were removed till healthy sclera was seen. Patients no. 1 and no. 3 were explored multiple times. This can be explained by the presence of tunnel lesion as described by Lin et al.  and Raber et al.  in patients with infectious scleritis. These lesions extend only into the deep layers of sclera with the superficial sclera and conjunctiva being infection free. Thus even after good cleaning of margins the infection tends to recur. One patient required a scleral patch graft after the primary lesion had resolved as there was a large area of uveal show.
In conclusion, a complete microbiological workup leads to an early and specific diagnosis. Along with intensive, prolonged topical and systemic medication; surgical debridement of the necrotic material is necessary for complete resolution of the disease.
Authors acknowledge the help of Ms Sarika Jain Antony and Dr Taraprasad Das for professional English editing of this manuscript.
Hyderabad Eye Research Foundation, Proff Brien Holden Eye Research Center.
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