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Cornea

Pigmented Corneal Lesions After Cataract Surgery

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Ophthalmology

Published Online: February 9, 2023

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Sarah Schimansky, MB BCh BAO¹;

Omar El Haddad, MB BCh^1,2

Author Affiliations

¹Bristol Eye Hospital, University Hospitals Bristol, Weston NHS Foundation Trust, Bristol, United Kingdom
²Faculty of Medicine, Alexandria University, Al Azaritah WA Ash Shatebi, Bab Sharqi, Alexandria Governorate, Egypt

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An 81-year-old woman was referred to our service for assessment of 3 darkly pigmented corneal lesions (Figure 1A). Two years ago, she underwent uncomplicated right cataract surgery at a different center. Her postoperative course had been complicated by persistent low-grade anterior uveitis for which she received maintenance loteprednol, 0.5%, eye drops on alternate days. She also used latanoprost eye drops at night in both eyes for primary open-angle glaucoma. Her medical history was only significant for hypertension, which was well controlled with ramipril. She denied any ocular trauma or recent travel outside of the country. Review of systems was unremarkable.

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Dematiaceous fungal keratitis

C. Obtain aqueous fluid for fungal polymerase chain reaction

The appearance of the pigmented corneal lesions is suspicious for a melanin-producing fungal infection. Dematiaceous fungi contain darkly pigmented hyphae and are ubiquitous in vegetation around the world. They are common causes of pigmented keratitis in tropical climates but uncommon in temperate regions.¹ Fungal infections should be considered in patients who are using long-term topical corticosteroids.²^,3 Other risk factors include diabetes, systemic immunosuppression, corneal decompensation, ocular trauma with plant material, and ocular surgery.²^,4 While fungal keratitis after cataract surgery, as in this case, has been described,⁵ the true incidence of postoperative fungal keratitis and endophthalmitis is not known.

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Article Information

Corresponding Author: Sarah Schimansky, MB, BCh, BAO, Bristol Eye Hospital, University Hospitals Bristol, Weston NHS Foundation Trust, Lower Maudlin Street, Bristol BS1 2LX, United Kingdom (sarah.schimansky@nhs.net).

Published Online: February 9, 2023. doi:10.1001/jamaophthalmol.2022.6308

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

Rai M , Ingle AP , Ingle P , et al. Recent advances on mycotic keratitis caused by dematiaceous hyphomycetes. J Appl Microbiol. 2021;131(4):1652-1667. doi:10.1111/jam.15008 PubMed Google Scholar Crossref

Mills B , Radhakrishnan N , Karthikeyan Rajapandian SG , Rameshkumar G , Lalitha P , Prajna NV . The role of fungi in fungal keratitis. Exp Eye Res. 2021;202:108372. doi:10.1016/j.exer.2020.108372 PubMed Google Scholar Crossref

Prajna NV , Krishnan T , Mascarenhas J , et al. Predictors of outcome in fungal keratitis. Eye (Lond). 2012;26(9):1226-1231. doi:10.1038/eye.2012.99 PubMed Google Scholar Crossref

Brown L , Leck AK , Gichangi M , Burton MJ , Denning DW . The global incidence and diagnosis of fungal keratitis. Lancet Infect Dis. 2021;21(3):e49-e57. doi:10.1016/S1473-3099(20)30448-5 PubMed Google Scholar Crossref

Mahmoudi S , Masoomi A , Ahmadikia K , et al. Fungal keratitis: an overview of clinical and laboratory aspects. Mycoses. 2018;61(12):916-930. doi:10.1111/myc.12822 PubMed Google Scholar Crossref

Knutsson KA , Iovieno A , Matuska S , Fontana L , Rama P . Topical corticosteroids and fungal keratitis: a review of the literature and case series. J Clin Med. 2021;10(6):1178. doi:10.3390/jcm10061178 PubMed Google Scholar Crossref

Maharana PK , Sharma N , Nagpal R , Jhanji V , Das S , Vajpayee RB . Recent advances in diagnosis and management of mycotic keratitis. Indian J Ophthalmol. 2016;64(5):346-357. doi:10.4103/0301-4738.185592 PubMed Google Scholar Crossref

Wykoff CC , Flynn HW Jr , Miller D , Scott IU , Alfonso EC . Exogenous fungal endophthalmitis: microbiology and clinical outcomes. Ophthalmology. 2008;115(9):1501-1507, 1507.e1-1507.e2. doi:10.1016/j.ophtha.2008.02.027 PubMed Google Scholar Crossref

Romaniuk W , Koziol H , Muskalski K , Dorecka M , Tarnawska D , Sabat D . A unique case of primary corneal melanoma. Jpn J Ophthalmol. 2002;46(1):114-116. doi:10.1016/S0021-5155(01)00462-2 PubMed Google Scholar Crossref

Uçakhan-Gündüz Ö , Gündüz K , Karsloğlu MZ , Okçu-Heper A , Kanpolat A . Corneal melanoma: report of three cases. Eye Contact Lens. 2012;38(5):341-344. doi:10.1097/ICL.0b013e318237d195 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.