Recurrent Paecilomyces Keratitis in a Patient with Jones Tube after Conjunctivodacryocystorhinostomy

Dear Editor, Paecilomyces, which is found in soil and decaying vegetables, is a rare pathogen causing local and systemic infections [1]. We report a rare case of recurrent Paecilomyces keratitis 5 years after Jones tube placement in conjunctivodacryocystorhinostomy (CDCR). A 69-year-old woman was referred by a local ophthalmologist for the management of presumed fungal keratitis in the left eye. One month before presentation, she noted ocular discomfort with decreased vision. She had undergone left eye ocular surgery of CDCR 6 years previous and cataract surgery 2 months previous. After CDCR, she had used daily topical tobramycin and 0.02% fluorometholone eye drops. No known history of ocular trauma, contact lens use, or herpes simplex keratitis was evident. At initial examination, her best corrected visual acuity was finger counting at 30 cm. Slit-lamp examination demonstrated a 2.0 × 2.0-mm-sized epithelial defect with corneal stromal infiltration. There was moderate anterior chamber reaction and linear hypopyon. Corneal scrapings were cultured and confirmed the diagnosis of Paecilomyces infection. Topical amphotericin B 0.125% and voriconazole 1% were started. After 4 weeks of topical antifungal therapy, the epithelial defect and hypopyon were resolved. Her vision was improved to 20 / 50, but corneal opacity and thinning remained. There was no evidence of recurrence during the follow-up. Five years later, the patient presented with reduced vision in the left eye; her visual acuity in the left eye was 20 / 1,000 with spectacle correction. Slit-lamp examination showed geographic ulceration and radial Descemet’s membrane folding at the central cornea including the site of previous corneal opacity and thinning (Fig. 1A and 1B). The additional presence of mild anterior chamber reaction and no hypopyon led to a diagnosis of herpes simplex keratitis, for which acyclovir ointment and topical moxifloxacin were started. Cultures showed no growth of any organism. Geographic ulceration and chamber reaction were improved, but the corneal thinning resulted in a perforation despite treatment. The patient emergently underwent amniotic membrane transplantation and corneal button graft. Two weeks later, she developed a recurrence of keratitis in the graft and 2.0-mm hypopyon. A therapeutic keratoplasty was performed. The previous corneal graft was Korean J Ophthalmol 2016;30(6):479-480 http://dx.doi.org/10.3341/kjo.2016.30.6.479 Correspondence