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Photo Essay Anterior segment optical coherence tomography of microsporidial keratoconjunctivitis Mittanamalli S Sridhar, Bajibhi Shaik Key words: Anterior segment optical coherence tomography, hyperreflectivity, microsporidial keratoconjunctivitis
A 17‑year‑old male patient presented with irritation and redness in the right eye of 1‑week duration. He gave a history of rainwater entering the right eye on the day of the onset of symptoms. Corneal examination of the right eye revealed multiple, whitish, coarse punctate corneal epithelial lesions of variable sizes [Fig. 1]. Anterior segment optical coherence tomography (AS‑OCT) showed intense hyper‑reflective epithelial lesions raised above the surface of the epithelium [Fig. 2a]. Corneal scraping revealed microsporidia. He was started on 0.5% moxifloxacin eye drops one drop six times a day along with lubricating drops and lubricating gel at bedtime. Following treatment, the epithelial lesions resolved. One week after corneal scraping large subepithelial nummular lesions were seen [Fig. 2b]. The subepithelial nummular lesions when first seen were larger compared to adenoviral subepithelial lesions [Fig. 2c]. These lesions faded over weeks.
Discussion Keratoconjunctivitis is the most common clinical manifestation of ocular microsporidiosis. [1] The typical corneal presentation in the form of multiple, whitish, raised, epithelial lesions which are varying in size.[2,3] On AS‑OCT, infiltration is seen as hyperreflective area.[4] The epithelial lesions in microsporidial keratoconjuctivitis can be of different types. (a) Smaller, faint white dots or round lesions. (b) Dense white, round to oval lesions. (c) Bizarre shape (pleomorphic lesions, varying in size and usually Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/ijo.IJO_1005_17 PMID: *****
Department of Ophthalmology, Krishna Institute of Medical Sciences Limited, Hyderabad, Telangana, India Correspondence to: Dr. Mittanamalli S Sridhar, Department of Ophthalmology, Krishna Institute of Medical Sciences Limited, Minister Road, Secunderabad, Hyderabad ‑ 500 003, Telangana, India. E‑mail:
[email protected] Manuscript received: 13.11.17; Revision accepted: 22.01.18
Figure 1: Slit lamp biomicroscope showing multiple, whitish, coarse punctate epithelial lesions of variable sizes at presentation
larger than the round‑to‑oval typed. (d). A target‑like lesions with a transparent hollow center.[3] On mild debridement or swabbing, the denser white lesions are removed leaving a punched out epithelial defect. The smaller lesions which are not removed become larger and prominent on follow‑up. Following treatment, the epithelial pattern evolves into a nummular pattern before resolution without scarring. Corneal edema and fine keratic precipitates may also occur.[5]
Conclusion AS‑OCT is a noncontact and noninvasive imaging technique that captures high‑resolution cross‑sectional images of the anterior segment. On AS‑OCT, the raised hyper‑reflective epithelial lesions of microsporidial keratoconjunctivitis can be differentiated from adenoviral nummular scars which are subepithelial lesions, seen as less intense hyperreflective
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[email protected] Cite this article as: Sridhar MS, Shaik B. Anterior segment optical coherence tomography of microsporidial keratoconjunctivitis. Indian J Ophthalmol 2018;66:691-2.
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lesions with the smooth epithelial surface. The subepithelial nummular lesions of microsporidial keratoconjunctivitis seen are larger compared to adenoviral subepithelial lesions when it first appears.
a
Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
b
References 1. Das S, Wallang BS, Sharma S, Bhadange YV, Balne PK, Sahu SK, et al. The efficacy of corneal debridement in the treatment of microsporidial keratoconjunctivitis: A prospective randomized clinical trial. Am J Ophthalmol 2014;157:1151‑5. 2. Sridhar MS, Sharma S. Microsporidial keratoconjunctivitis in a HIV‑seronegative patient treated with debridement and oral itraconazole. Am J Ophthalmol 2003;136:745‑6.
c
3. Fan NW, Lin PY, Chen TL, Chen CP, Lee SM. Treatment of microsporidial keratoconjunctivitis with repeated corneal swabbing. Am J Ophthalmol 2012;154:927‑330.
Figure 2: (a) Anterior segment optical coherence tomography presentation showing multiple hyper‑reflective epithelial lesions of microsporidial keratoconjuctivitis which are raised above the epithelial surface. (b) Anterior segment optical coherence tomography of same patient 1 week after treated showing large sub‑epithelial nummular lesions. (c) Anterior segment optical coherence tomography of adenoviral (diagnosed clinically) showing smaller nummular lesions which are seen as sub‑epithelial hyper‑reflective lesions. Note the smooth epithelial surface
5. Loh RS, Chan CM, Ti SE, Lim L, Chan KS, Tan DT, et al. Emerging prevalence of microsporidial keratitis in Singapore: Epidemiology, clinical features, and management. Ophthalmology 2009;116:2348‑53.
4. Konstantopoulos A, Kuo J, Anderson D, Hossain P. Assessment of the use of anterior segment optical coherence tomography in microbial keratitis. Am J Ophthalmol 2008;146: 534‑42.
