A 65-year-old man complained of a white mass on the lower conjunctiva that had formed since 2 months associated with pain and redness in the right eye. His right eye vision was 20/100. He was receiving topical gatifloxacin eye drop four times per day, tobramycin eye drop every hour, and oral analgesic twice daily. On examination the lower fornix had localized circumscribed area of scleral abscess with engorged episcleral and conjunctival vessel around it. Smear and culture revealed Nocardia species, sensitive to amikacin (Table 1). The patient was initiated on topical amikacin 2.5% every half hour and oral trimethoprim (160 mg)–sulfhamethoxazole (800 mg), twice daily. The abscess persisted despite treatment with culture adjusted antibiotics for 6 weeks. Hence we explored the sclera to express out purulent material. Postoperatively topical gatifloxacin every hour was added to previous treatment. The lesion persisted for the next 3 weeks and hence the abscess was again re-explored. Apart from the infected area a thorough cleaning of healthy margin was done looking specifically at any extension to the surrounding area. Postoperatively we continued the same medications. Systemic antibiotic were continued for 2 months. At fourth month of treatment his vision was 20/60 and there was granulation tissue at the lesion site. A slit lamp examination revealed that he had nuclear sclerosis.

A 50-year-old lady with history of injury to the right eye with some plant material 2 1/2 months ago developed pain, redness and watering. She was on topical levofloxacin and lubricant. Her vision was 20/30 in right eye and 20/20 in left eye. The right eye showed a well-localized, circumscribed abscess and a scleral ulcer discharging purulent material in the inferior bulbar conjunctival area (Fig. 1a).The abscess was drained and the surrounding necrotic tissue was removed. Smear and culture of the exudates were positive for Nocardia species (Fig. 1b). Topical amikacin 2.5% every hour, ciprofloxacin 0.3% every hour, homatropine twice daily, and oral ciprofloxacin 500 mg twice daily was given. After 3 weeks of treatment there was no area of scleral suppuration or ulcer, conjunctiva was mildly congested, and there was an area of uveal show (Fig. 1c) under the conjunctiva. A donor scleral patch graft with amniotic membrane graft over it was done. Postoperatively we advised topical prednisolone acetate eight times a day, ciprofloxacin 0.3% every hour, and oral ciprofloxacin 500 two times a day. The systemic medication was discontinued after a week, topical corticosteroids were tapered, and antibiotic was continued for 2 months. Four months postoperatively her best corrected visual acuity was 20/20 with a healthy graft.

A 55-year-old lady presented with a history of pain and redness in the left eye for 2 months. She was on oral prednisolone (1 mg/kg body weight), and topical chloramphenicol-dexamethasone for the last 2 months. Her vision in the left eye was 20/200. Slit lamp examination of the left eye showed a circumscribed abscess in the superior bulbar area and cataract. Scleral exudates showed thin acid fast branching filaments under microscope and culture revealed Nocardia asteroides (identified based on biochemical tests). She was initiated on topical amikacin 2.5% and ciprofloxacin 0.3% every hour and oral ciprofloxacin 500 mg twice daily. The sclera was explored twice because of recurrence in the inferotemporal quadrant. Postoperatively she was advised topical amikacin 2.5% and gatifloxacin 0.3% every hour along with systemic gatifloxacin 400 mg once daily. At 3 months follow-up the corrected visual acuity at 20/50; there was cataract, though the sclera was thinned and there was uveal show.

The conjunctiva overlying the suppurated area was excised. The suppurated material along with necrotic sclera was removed. These were sent for a microbiology evaluation. Care was taken to clean the margin as far as possible to obtain a healthy sclera. The base and margin were irrigated thoroughly. Postoperatively subconjunctival amikacin was injected to the surrounding conjunctiva. At the end of surgery the conjunctiva was not closed. This helps in the penetration of the topical medication

The scleral scrapings/exudates were subjected to microscopic examination (Gram stain, modified Zeihl Neelsen stain using 1% H₂SO₄) and culture on sheep blood agar, chocolate agar, brain heart infusion broth, thioglycollate broth, and Sabouraud dextrose agar. Microscopic examination of the scleral exudates showed acid fast thin, beaded, branching filaments in all patients. In all cases, slow growing, chalky white dry colonies grew on blood and chocolate agar. Based on biochemical tests such as urease production, hydrolysis of casein, xanthine, tyrosin, and growth in gelatine, one of the isolates was identified as N. asteroids. (The susceptibility of the isolates was tested on Muller Hinton blood agar by disk diffusion method).

Hyderabad Eye Research Foundation, Proff Brien Holden Eye Research Center.

None.

This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution and reproduction in any medium, provided the original author(s) and source are credited.

OD right eye, OS left eye, NA not available, VA visual acuity, TMP-SMX trimethoprim 160–800, PPV pars plana vitrectomy

+ sensitive, − resistant, ND not done