A 35-year-old lady, who worked in the royal stable, presented with redness and decreased vision in her right eye of 15 days duration. She was initially treated at a local health center for a corneal abrasion in her right eye, after being hit by the tail of a horse while cleaning the stable. She applied honey three times everyday to her painful right eye as advised by a local traditional healer. A week later, the pain in her eye decreased, but the vision in the right eye deteriorated and redness increased.\nAt the time of presentation, she had no pain or photophobia. The best corrected vision in the right eye was counting fingers at 2 m, and left eye was 0.5 with +2.0 D sph. The right eye showed ciliary congestion. A central corneal ulcer measuring (2 × 3 mm) in size with a hypopyon was noted. Culture of the scrapings from the ulcer grew dermatophytes on Sabouraud agar, which was identified as T. mentagrophytes. There was no evidence of superficial mycoses affecting skin, nails or any other area of her body.\nThe ulcer was treated with topical antifungal drops (Fluconazole 0.3%; Zocon® FDA Ltd) every hour, and cycloplegic (Cyclopentolate hydrochloride 1%; Mydrilate® Intrapharm) three times daily. Ten days following treatment, the patient underwent therapeutic keratoplasty for a non-healing corneal ulcer with impending perforation. The graft was clear and the eye quiet with a visual acuity of 0.2 on the first postoperative day. The topical medications were continued post-keratoplasty. However, the primary infection recurred involving the graft by the fourth postoperative day, progressing relentlessly to involve the entire graft by the 15th day resulting in a vascularized central scar by 2 months (). Posterior segment of the eye and the vitreous cavity appeared normal on B scan ultrasonography. Intra ocular pressure was 10 mmHg. The final visual acuity at the end of 2 months was appreciation of hand movements in the right eye.
A 60-year-old Pakistani male with a history of acute exacerbation of open angled glaucoma of the right eye underwent branding of the right temple and vertex by a faith healer. Four days later, he presented to the hospital with blurry vision in the right eye and cellulitis over the right temporal region. Further examination revealed chemosis, corneal haziness, severe restriction of ocular movements and multiple well circumscribed round full-thickness burns ranging from 2 to 5 cm with no evidence of active drainage. Fundoscopy showed papilledema and hemorrhages with engorgement of veins. On day five, similar signs appeared in the contralateral eye. His past medical history was insignificant except for glaucoma. He had no prior history of sinus headaches or ear infections. Since local infection is the major reason for cavernous sinus thrombosis (CST), the diagnosis was suspected in our patient as the typical sequelae had started after branding. Acute glaucoma can sometimes present with CST; however, he was already on treatment for open angled glaucoma and had no previous infection. The fact that he had acute exudative wounds after branding and had no prior history of ear or sinus infections points towards branding as a cause of CST. Our diagnosis was confirmed by magnetic resonance imaging (MRI). We believe this local inflammation and infection may have spread and reached one of the cavernous sinuses which may turned into an infected clot. The patient partially responded to intravenous broad-spectrum antibiotics (Amoxicillin with clavulanic acid and Ceftriaxone) and local wound management, but suffered permanent blindness.