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  • Grand Rounds

    A patient five months after bilateral simultaneous cataract surgery in another country presents to the BPEI emergency room with bilateral decreased vision and extreme right eye pain for the last 2 weeks. Their exam was notable for visual acuity of hand motion in the right eye and 20/150 in the left eye. Slit lamp exam was most notable for multifocal limbal infiltrates with associated scleritis and anterior chamber inflammation in both eyes. The left eye dilated fundus exam was within normal limits and the B-scan in the right eye, performed due to poor posterior segment view, showed vitreous debris without membranes. Patient was immediately cultured and started on fortified topical antibiotics in both eyes. In the next month, multiple corneal biopsies and anterior chamber washout were performed to attempt identification of this indolent organism contracted after simultaneous operations. The right eye progressed to scleral uveal show and limbus-to-limbus infiltrate despite aggressive antibiotic therapy and the left eye has slightly worsened scleritis and keratitis despite aggressive topical, intrastromal, subconjunctival and oral antibiotic therapy. Patient elected for enucleation of his right eye 35 days after presentation. 5 days later, the organism was identified as Myobacterium Abscessus subsp. Bolleti, a highly resistant nontuberculous mycobacteria. This patient was then admitted inpatient for aggressive intravenous anti-tuberculous antibiotic therapy. Despite 40 days of inpatient systemic antibiotics, in addition to the 80 days of topical, and local infiltrative antibiotics treatment, patient’s limbal corneal lesions in his left eye seem to have slowly migrated centrally. Given the lack of efficacy with antibiotics, anterior lamellar keratectomy with cryotherapy, rose Bengal-photodynamic therapy, and conjunctival flaps as performed on this patient’s only remaining eye. Post-operatively, patient was able to be discharged from the hospital while continuing on home systemic antibiotics. At post-operative month 3, patient’s vision has improved to 20/40 at near and the keratitis has not returned.

    Presentation Date: 02/23/2023
    Issue Date: 03/10/2023