a healthy 60-year - old male with a 30 pack - year smoking history presented with 2 months of right eye pain , headache , and photophobia .
his ocular history was significant for pterygium excision with mitomycin c in the right eye 5 years ago as well infiltrative infectious scleritis secondary to enterobacter cloacae and curvularia fungus species 2 years ago .
his first episode of the right eye infectious scleritis presented as scleral thinning 3 mm nasal to the limbus with overlying infiltrates that resolved with topical moxifloxacin and natamycin over the course of 3 months . however , a residual calcified plaque remained in the area of scleral thinning .
two years later , the patient returned complaining of several weeks of worsening pain and photophobia in the right eye . on examination ,
his best - corrected visual acuity was 20/25 in the right eye and 20/20 in the left eye .
examination of the right eye revealed soft , yellow - white purulent material overlying the existing calcified plaque with extensive scleral thinning [ fig . 1 ] .
slit - lamp photograph of the right eye 2 years after initial presentation , now with an elevated mass of purulence overlying the area of scleral thinning a limbal peritomy was performed to define the areas of scleral thinning , and the purulent material was noted to be adherent to the calcific plaque .
the plaque and purulent material were excised with gentle traction and sent for culture and histopathology . to avoid scleral perforation , a tutoplast scleral graft was sutured over the scleral defect and covered with a conjunctival flap .
initially , the patient was treated with hourly topical moxifloxacin , fortified tobramycin , and natamycin .
gomori methenamine silver stains of the purulent material eventually revealed a marked amount of branching fungal hyphae ( indicated by arrow ) with cultures growing pseudomonas aeruginosa and bipolaris fungus [ fig . 2 ] .
gomori methenamine silver stain of purulent area demonstrating numerous branching hyphae ( arrow ) indicative of fungus nine days after the procedure , the patient developed moderate discomfort in the right eye .
examination revealed a retracted conjunctival flap with further purulent material overlying the scleral patch graft .
a decision was made to inject subconjunctival voriconazole , and qid dosing of topical cyclosporine 2% plus oral ketoconazole ( 400 mg daily ) was added to his treatment plan .
after 10 weeks of treatment , the patient 's symptoms had resolved , and vision returned to baseline [ fig . 3 ] . once clinical evidence of infection resolved , medications were discontinued .
slit - lamp photograph of the right eye on postoperative month 3 with epithelialization of the scleral patch graft and resolved infection
in our patient , aggressive medical and surgical management resulted in complete resolution of the infection .
surgical intervention was elected due to the chronicity and recurrence of the lesion and due to the possibility of impending scleral perforation . in vitro strains of dematiaceous fungi
have shown to respond well to antifungals such as natamycin and amphotericin b. hence , a suggested clinical treatment modality includes topical natamycin 5% supplemented with oral ketoconazole .
keratitis has been shown to resolve in over 70% of cases with dematiaceous fungi , but poor penetration of antimicrobials through the collagen - bound scleral layer poses a challenge for effective treatment .
the persistence of organisms such as pseudomonas species and fungal hyphae in the sclera despite aggressive medical therapy has been reported .
for such cases of infectious keratoscleritis that are refractive to medical treatment such as this particular case , the best option may be to include surgical management such as excision with lamellar corneoscleral graft and/or cryotherapy .
infectious scleritis typically presents as an extension of keratitis resulting from ocular injury , often from trauma , foreign bodies , radiation , or surgery .
infectious scleritis following pterygium removal has been reported , and is often related to postoperative beta irradiation and/or intraoperative antimetabolites .
the events resulting in an infection involve direct pathogenic invasion of the sclera that triggers an immune - mediated vasculitis and necrosis at the site of pterygium excision .
hence , if a presumed inflammatory scleritis does not respond as expected to steroid treatment , an infectious etiology should be considered .
such cases can be diagnosed through smear / culture , scleral biopsy , or anterior chamber aspirate .
poor prognosis in infectious scleritis includes corneal involvement , inappropriate antimicrobial therapy , and presence of fungal infection .
thus , mycotic scleritis should always be considered in the differential diagnosis , and prompt diagnoses and treatment are critical to salvage vision . to our knowledge , this is the first report of infectious scleritis without corneal involvement caused by the bipolaris species .
 we report an interesting case of infectious scleritis from coinfection of pseudomonas aeruginosa and bipolaris with no corneal infiltrate . a healthy 60-year - old man with a history of infectious scleritis following pterygium excision presented with purulent material growing p. aeruginosa and 1 + colonies of bipolaris species of fungus . 
 broad spectrum treatment was initiated with hourly topical moxifloxacin , fortified tobramycin , and natamycin along with a subconjunctival injection of voriconazole and topical cyclosporine , with po ketoconazole . 
 after 10 weeks of aggressive empiric treatment , the patient 's symptoms had resolved , and his vision returned to baseline although a scleral patch graft was utilized to stabilize scleral thinning . 
Case Report
Discussion
Financial support and sponsorship
Conflicts of interest