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Purpose: To report the management and outcome of a case of necrotizing scleritis due to Hormographiella aspergillata ., Methods: Case report., Results: A 79-year-old woman developed scleral inflammation following accidental trauma with a gorse plant in her left eye. An abscess formed at the site of the injury, which was surgically drained. Filamentous fungi were identified from the abscess contents, and oral voriconazole and topical voriconazole and natamycin drops were prescribed. Phenotypic analysis confirmed the presence of Hormographiella aspergillata , with low minimum inhibitory concentrations (MIC) for voriconazole and amphotericin B. Two weeks later the patient presented with an area of necrotizing scleritis which required surgical debridement and scleral grafting. Three months later, the scleral inflammation had resolved leaving an area of scleromalacia., Conclusions: Hormographiella aspergillata is a common environmental fungus that has recently emerged as a human pathogen and a rare cause of scleritis. To the best of our knowledge, this is the first report of scleritis in which a pure culture of H. aspergillata was obtained. Successful management poses a challenge as there are limited reports on antifungal susceptibility and a combination of medical and surgical treatment is often required.

Purpose: To report a highly unusual and fulminant case of infectious fungal panophthalmitis that initially presented as angle closure in the setting of posterior scleritis, culminating in the loss of the affected eye., Observations: A 57-year-old woman with a history of poorly controlled diabetes mellitus and autoimmune disease presented with a unilateral flat anterior chamber, highly elevated intraocular pressure (50-65 mmHg) and severe chemosis of the right eye. Initial VA was NLP in the affected eye. An ultrasound B-scan revealed a very pronounced T-sign and severely thickened posterior sclera and choroid indicative of posterior scleritis. Bloodwork showed elevation of WBC count to 18 K/μL and broad spectrum antibiotics were initiated. However, a comprehensive infectious workup including fungal cultures were persistently negative. After three days of IV NSAIDs and antibiotics, WBC count normalized and pain had mildly improved. After consultation with a multidisciplinary team that included the Glaucoma, Retina/Uveitis, Infectious Disease, Rheumatology and Internal Medicine services, high dose IV methylprednisolone was started. Despite the initial improvement, corneoscleral decompensation and paralimbal perforation of the globe occurred. The eye was enucleated, and pathologic examination revealed a dense focus of budding yeast in the vitreous cavity., Conclusions and Importance: Scleritis is a rare entity, with posterior scleritis, infectious scleritis, and fungal scleritis representing increasingly rare subtypes. However, fungal scleritis may be underdiagnosed due to a number of factors including culture negativity, a lack of clinical suspicion, as well as the disease's propensity to masquerade as other pathologies such as angle closure or malignant glaucoma. Fungal scleritis should be considered in cases that present with possible infectious etiology, worsen with systemic corticosteroid treatment, or worsen despite broad-spectrum antibiotic coverage. When treating patients with underlying risk factors such as uncontrolled diabetes mellitus, recent antibiotic use, use of total parenteral nutrition, or immunosuppression, a higher level of suspicion for fungal etiology is also appropriate. In the outpatient setting, fungal eye infections do not always present with critical systemic illness or culture positivity. If there is suspicion for fungal involvement, early aqueous or vitreous tap may improve diagnostic yield., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors have no conflict of interest., (© 2023 The Authors.)

Scleritis is a rare painful ocular disorder, associated with severe ocular pain and tissue destruction. Although a majority of these cases are immune mediated and at least half of these are associated with systemic immune-mediated diseases, a smaller minority are due to infections of the sclera. The two conditions closely mimic each other, and a thorough knowledge of the subtle differences is necessary in order to reach a timely diagnosis. Diagnostic delay can lead to a poor outcome both due to the destruction caused by the uncontrolled infection and also due to propagation of the infection with the use of corticosteroids which may have been started for presumed immune mediated scleritis. In this review, we present the clinical features, etiological agents, and the differentiating features between immune and infectious scleritis. We also present diagnostic and management guidelines for managing scleral infection., Competing Interests: None

An otherwise healthy 62-year-old woman developed necrotizing scleritis 23 years following pterygium excision with adjunctive beta-radiation. Surgically induced necrotizing scleritis (SINS) was diagnosed, but the scleritis progressed despite anti-inflammatory therapy, and 10 weeks after presentation the patient developed a hypopyon and decreased vision. After cultures revealed no growth at 72 hours, immunosuppressive therapy was escalated, with a subsequent deterioration in the patient's clinical course. Scedosporium superinfection was eventually cultured and found on histological examination of the enucleated globe. In reported cases, infectious scleral necrosis occurs most commonly following pterygium (71.4%) and scleral buckling (97.2%) surgery. Hypopyon is uncommon (10.0%) in patients with postoperative scleral necrosis, but when present is a strong predictor of infection (odds ratio, 21.2; 95% confidence interval, 2.9-157.5). Rates of underlying autoimmune disease are generally low (0.0-12.5%) except following cataract and lens procedures, where the occurence of SINS heralds systemic illness in 42.9% of cases., (Copyright © 2013 Elsevier Inc. All rights reserved.)