Fungal keratitis in Lattice dystrophy

We report a case of fungal keratitis occurring in a patient with lattice dystrophy. A 57-year-old farmer presented with a corneal ulcer following probable entry of paddy husk in the right eye, of one month duration. Corneal scraping revealed pigmented fungal filaments while culture grew Alternaria alternata. Treatment with 5% natamycin eye drops and 1% atropine healed the infection in four weeks. We would like to draw attention to the fact that the cornea in lattice dystrophy is prone to frequent erosions and is a compromised epithelial barrier to invasion by microorganisms. Patients must be made aware of this fact and should seek attention at the earliest following any trivial trauma. Management of minor corneal abrasions in them should be directed at healing the epithelium with adequate lubricants and preventing infection with topical antibiotic prophylaxis.

a potential for improvement in visual acuity, although with inherent risks associated with intravitreal injections. A longterm follow-up is warranted to address possible recurrences and determine the optimal number of re-treatments required in achieving a long-term stabilization of the aforesaid condition.

Samrat Chatt erjee, Deepshikha Agrawal
We report a case of fungal keratitis occurring in a patient with latt ice dystrophy. A 57-year-old farmer presented with a corneal ulcer following probable entry of paddy husk in the right eye, of one month duration. Corneal scraping revealed pigmented fungal filaments while culture grew Alternaria alternata. Treatment with 5% natamycin eye drops and 1% atropine healed the infection in four weeks. We would like to draw att ention to the fact that the cornea in latt ice dystrophy is prone to frequent erosions and is a compromised epithelial barrier to invasion by microorganisms. Patients must be made aware of this fact and should seek att ention at the earliest following any trivial trauma. Management of minor corneal abrasions in them should be directed at healing the epithelium with adequate lubricants and preventing infection with topical antibiotic prophylaxis. Latt ice dystrophy of the cornea is a bilateral, inherited, primary, localized corneal amyloidosis characterized by subepithelial opacities, stromal white dots, refractile fi lamentary lines and stromal haze giving rise to recurrent corneal erosions and irregularity of the epithelium with accompanying decrease in visual acuity. [1] Recurrent erosion and an unhealthy epithelium in latt ice dystrophy may predispose the cornea to microbial infections. [2] Few such cases have been reported in the literature with bacterial and viral infections. [2][3][4] We report an uncommon case of fungal keratitis in a patient with latt ice dystrophy.

Case Report
A 57-year-old farmer presented with complaints of pain, redness, watering and reduced vision in the right eye, of onemonth duration. There was a vague history of entry of paddy husk in the eye. He also gave a history of repeated episodes of foreign body sensation, pain and watering in both the eyes since fi ve years. His visual acuity in the right eye was counting fi ngers at 2 m while in the left eye was 20/20. There was nasal pterygium in both eyes. There were no signs of blepharitis or meibomitis. There was a para-central epithelial defect with dry, white, full-thickness stromal infi ltrate of 3 ϫ 2.5 mm diameter [ Fig. 1a]. There were multiple linear refractile lines consistent with latt ice-lines in the corneal stroma extending to the periphery [ Fig. 1b

Discussion
Recurrent erosions in latt ice dystrophy have been postulated to be due to abnormal basement membrane complexes that provide poor epithelial stromal adhesions or an abnormal basal epithelial cell wall incapable of providing normal structural integrity to the epithelial layer. [2] Thus the corneas in latt ice dystrophy with recurrent erosions are susceptible to infections due to breach in the normal epithelial barrier. Further, because of compromised epithelial layer, healing is delayed. Goodall et al., [2] have reported two patients with mixed bacterial infections while others have reported patients with bacterial and viral infection or of unknown etiology. [3][4][5] Thus occasionally the chronic course of latt ice dystrophy may be altered to a sight-threatening ocular emergency with infection by pathogenic microorganisms.
Our patient suffered from an infection with Alternaria alternata following probable entry of paddy husk. Although ubiquitous in the environment, Alternaria species are not a common ocular pathogen in the etiology of fungal keratitis in India. [6] Minor trauma to the eye due to paddy is a common  risk factor for keratitis in agricultural communities, in whom the incidence of fungal keratitis is highest in India. [6] However, all such incidents do not result in ulcer unless there is a breach in the corneal epithelium, delay in healing that provides the "window of opportunity", [7] lodgment of the microorganism and development of subsequent ulceration. Oft en it may be diffi cult to ascertain whether the sequel of corneal ulceration in this group of patients is because of direct trauma or because of the poorly healing epithelium. Clinically, it may also be diffi cult in the early stages to diff erentiate corneal erosions from infections. Further symptoms of recurrent corneal erosion in latt ice dystrophy need to be distinguished from symptoms of lid margin disease which is commonly present in the general population. Nevertheless the compromised epithelium in latt ice dystrophy is prone to frequent erosions and poor healing and thus provides the necessary milieu for the development of fungal keratitis.
In conclusion we would like to draw the att ention of all ophthalmologists to the risk of microbial keratitis in patients with latt ice and other epithelial and stromal dystrophies which compromises the corneal epithelial barrier. Patients should be advised about using protective glasses during their work to avoid entry of foreign body or mild trauma. Further, those suff ering from mild ocular surface abrasion following trauma may benefi t from prophylaxis with topical antibiotics [7] and suffi cient lubricants to promote healing.

Özlem Gürses Sahin, Aysel Pelit 1 , Tuğba Turunc 2 , Yonca Aydin Akova 1
We report a rare presentation of brucellosis as bilateral optic nerve and right abducent nerve involvement, and endocarditis complicated by right premacular hemorrhage in a 28-year-old white female. The patient showed improvement with both medical and surgical therapy. Brucellosis should be considered in the differential diagnosis of papillitis, gaze palsy and endocarditis complicated with premacular hemorrhage in endemic regions. Brucellosis, which is endemic in Turkey, is a systemic infection that can aff ect any organ or system in the body. [1] The most common ocular manifestations of brucellosis are considered as anterior uveitis and choroiditis. [2] We report a rare case of brucellosis with bilateral involvement of optic nerve, involvement of right abducent nerve, and endocarditis complicated by premacular hemorrhage. To our knowledge, premacular hemorrhage secondary to brucella endocarditis is the fi rst to be reported.

Case Report
A 28-year-old white female with a history of acute rheumatic fever and aortic valve insufficiency presented with poor physical condition associated with headache, fever, sweating and neck stiff ness. She also showed sudden onset of painless blurred vision in the right eye associated with diplopia. Best corrected visual acuity of the right eye was 20/400 and the left eye was 20/50. She had right aff erent pupillary defect and sluggish response to light on the left side. She had 30-45 prism diopters of right esotropia. The patient had reduced sensitivity to color vision higher in the red-green direction than in the blue-yellow direction in both eyes. The right fundus revealed 1 ½ disc diameter of premacular hemorrhage [ Fig. 1]. Right and left optic disc showed marked swelling and hyperemia associated with peripapillary vascular changes and fl ameshaped hemorrhages [ Figs. 1 and 2]. Cranial CT and MRI scans were normal. Echocardiography disclosed vegetation on the aortic valve. Seroagglutination test for brucella was positive over 1/320 dilution. Cerebrospinal fl uid (CSF) agglutination titer for brucella was positive over 1/32 dilution. CSF opening