A 54-year-old female patient presented to us with pain,\nswelling of lids of the right eye (RE) associated with intense\nchemosis and congestion of the conjunctiva. She was a\nknown diabetic since 20 years and a hypertensive since\n15 years. She had received posterior subtenon triamcinolone\n20 mg injection with a 20-gauge veinflow canula in her RE\nimmediately following focal laser treatment 3 days back for\ndiabetic macular edema. At presentation her vision in RE was\nhand movement close to face (HMCF) and the same in the\nleft eye (LE). Intraocular pressure could not be measured in\nRE due to massive lid edema. It was recorded as 14 mmHg in\nLE. The RE revealed lid edema with erythema []. The\ntemperature of the overlying skin was raised but there was no\npalpable mass. The conjunctiva was congested and chemosed.\nExtraocular movements were limited in all directions of gaze\nin RE. In LE the movements were full in all directions. On\nforcibly lifting the upper lid of RE there was frank white\ntenacious discharge from the site of subtenon injection along\nwith necrosis of the surrounding conjunctiva and peripheral\ncorneal infiltrate []. Pupillary reaction was normal.\nPosterior segment examination showed proliferative diabetic\nretinopathy (PDR) with clinically significant macular edema\n(CSME) in both eyes.\nMicrobiological investigation of the discharge and infiltrate\nshowed the presence of gram-positive cocci in clusters but no\ngrowth was observed on culture. Her fasting blood sugar was\n284 mg% at presentation. Thereafter she was started on insulin\ninfusion along with intravenous ciprofloxacin 500 mg twice\ndaily, vancomycin 1 g twice a day and metrogyl 80 mg twice\ndaily along with topical moxifloxacin 0.3% six times a day and\natropine thrice a day. She had previously received injection\ncefazolin and ciprofloxacin elsewhere for 1 day. Computed\ntomography (CT) of head was consistent with diagnosis of\norbital abscess [] with no involvement of optic nerve.\nThere was no evidence of intracranial involvement.\nOver the next 3 days there was very little improvement. At\nthis moment oral linazolid 500 mg twice a day was added to the\ndrug regimen suspecting methicillin and vancomycin-resistant\nStaphylococcus aureus. There was remarkable improvement in\nthe ensuing 48 h. Lid edema reduced considerably along with\ndecrease in conjunctival chemosis and congestion. Extraocular\nmovements improved and the discharge was seemingly much\nless than before. The above treatment continued for a period\nof 7 days. At 3 weeks follow-up all parameters were normal\nexcept for adjacent conjunctival and corneal scarring [].\nVisual acuity improved to 20/200. There was no restriction of\nocular movements.
A 69-year-old Japanese woman had a macular oedema in her right eye, which occurred secondary to BRVO and was unresponsive to intravitreal injection of anti-vascular endothelial growth factor aflibercept. She was subsequently treated by STTA injection at the referral hospital twice. During the treatments, her eye was anaesthetized with 4% topical lidocaine. A sterilized eyelid speculum was used, and the superior-temporal conjunctiva was incised using sterilized scissors to inject 20 mg of triamcinolone acetonide into the posterior subtenon space. After the injection, the conjunctiva was not sutured because this step is usually unnecessary. These procedures were performed in an outpatient treatment room with wearing sterilized gloves. A 1.5% topical levofloxacin ophthalmic solution was administered four times daily for 3 days post-injection. Four months after the second injection, the patient noted a conjunctival mass that became progressively larger with a little pain and redness. She was then referred to Kindai University with a clinical diagnosis of orbital fat herniation.\nDuring her first visit, best-corrected visual acuity (BCVA) was 6/30 in the right eye and 6/6 in the left eye. Intraocular pressure was normal in both eyes. Slit-lamp microscopic examination revealed no inflammation in both the anterior chamber and vitreous. A soft, well-demarcated mass mimicking herniated orbital fat was observed in the super-temporal quadrant, which corresponded to the posterior STTA site (Fig. a). Magnetic resonance imaging (MRI) of the orbits revealed a hypo-intensity lesion on T2-weighted imaging at the super-temporal peribulbar area (Fig. b). Her white cell count and C reactive protein levels were normal.\nTo excise the conjunctival mass, first, we made an incision in the conjunctiva, and found that yellowish pus was discharged. The local administration of antibiotics was performed empirically based on the presumed diagnosis of bacterial infection. Although a strain of dematiaceous fungi was isolated from the pus 1 month later, the antifungal drug susceptibility of the strain was not determined at that time. We did not immediately administer antifungal drugs because there were no significant changes in clinical findings initially. The abscess was debrided again 2 months after the surgery through a superior forniceal incision because the orbital abscess at the same lesion had developed gradually. During the second surgery, the wound was irrigated with 0.1% amphotericin B after three large abscesses were removed. Postoperatively, she was treated with 400 mg/day of oral voriconazole because of Fungiflora Y staining of the pus (Fig. a) and the presence of a large amount of fungi by pathological examination of the abscess by Grocott’s staining (Fig. b).\nWe obtained the pathogenic strain from the abscess during the second surgery and observed it macroscopically and microscopically. The colony on potato dextrose agar medium (PDA; Difco, Becton, Dickinson and Company, Sparks, USA) had a diameter of 10 mm 14 days after inoculation and with incubation at 25 °C. The colony appeared as a moist-form pigmented yeast-like colony (Fig. a). The slide culture using lactophenol cotton blue staining revealed cylindrical conidogenous cells producing ellipsoidal conidia (Fig. b). From the Basic Local Alignment Search Tool search using the sequence of the ribosomal RNA gene internal transcribed spacer domain base, the sequence (the accession number LC566592 in the DDBJ) of this strain showed 100% similarity to those of some strains of E. dermatitidis. The isolate was thus identified as E. dermatitidis on the basis of morphology and phylogeny. The pathogenic strain in the current case was deposited at the Medical Mycology Center, Chiba University in Japan, as IFM 65961.\nMinimum inhibitory concentrations (MICs) of several antifungal drugs and the minimal effective concentration of micafungin against the strain were determined using of the broth dilution method according to M38-A2 of the Clinical and Laboratory Standard Institute (Table ). The inhibitory concentrations of amphotericin B, itraconazole, voriconazole, and miconazole against the pathogenic strain were found to be low. Based on these results, topical and systemic voriconazole were administered for 3 months. The patient’s serum beta-D-glucan levels were normal during the follow-up periods since the first surgery, and no recurrence was observed after the second drainage.