CASE REPORT Aspergillus-induced Malignant Glaucoma Vandana Jain, MD,* Aniruddha Maiti, MD,† Debraj Shome, MD, FRCS,‡ Nishikant Borse, MD,† and Sundaram Natarajan, MD† Purpose: To report a case of Aspergillus flavus–induced kerato- mycotic malignant glaucoma. Methods: A 48-year-old woman presented with a severe corneal ulcer. She had received topical steroids for 10 days before presentation. Results: Microbiological studies revealed A. flavus as the offending pathogen. Nonresponsive high intraocular pressure with associated shallow anterior chamber was present. With a diagnosis of keratomycotic malignant glaucoma, the patient underwent thera- peutic keratoplasty with cataract extraction with posterior chamber wash. However, there was a recurrence of malignant glaucoma in the postoperative period. Patient underwent limited pars plana vitrectomy. Conclusions: Keratomycotic malignant glaucoma is a rare com- plication of severe fungal ulcer. We believe that the use of topical steroids in this case probably led to increased fungal penetration, with the formation of a lens–iris fungal mass and subsequent malignant glaucoma. Nonresponse to medical therapy warrants urgent surgical intervention. To the best of our knowledge, Aspergillus-induced keratomycotic glaucoma has never been reported previously. This report also highlights that therapeutic keratoplasty with cataract extraction alone may not be sufficient for management of such cases, and a limited pars plana vitrectomy may be needed. Key Words: keratomycotic malignant glaucoma, keratitis, fungal infection (Cornea 2007;26:762–763) K eratomycotic malignant glaucoma is a poorly recognized condition affecting cases with severe fungal corneal ulcer. Fungus penetrates into the anterior chamber and facilitates the formation of a lens–iris–fungal mass at the pupillary area, thereby causing the diversion of aqueous, leading to a high intraocular pressure. 1 Thus far, the reported cases have been seen in association with Fusarium keratitis. 1–3 We are reporting keratomycotic malignant glaucoma in a case of Aspergillus flavus keratitis. Also, this report highlights that lens removal and a posterior chamber wash, at the time of therapeutic keratoplasty, may not be sufficient in managing this condition, contrary to what has been previ- ously reported. 1 Limited pars plana vitrectomy to break the pathogenetic cycle is necessary, and a failure to do so may lead to the recurrence of the condition in the postoperative period, necessitating repeat surgery for management of this condition. CASE REPORT A 48-year-old woman presented with a history of pain, redness, and decreased vision of the right eye of 16-day duration. She had previously been treated with topical steroids for a period of 10 days by a local ophthalmologist. There was no history of any previous eye surgery. On examination, the best-corrected visual acuity (BCVA) was perception of hand movement close to her face in the right eye and 6/6 in the left eye. Left eye examination was within reference limits. In the right eye, the cornea revealed a total, full-thickness infiltrate, with irregular feathery margins. Corneal scrapings were performed, which showed fungal hyphae on KOH mount, later identified as A. flavus. The intraocular pressure (IOP), which was digitally measured, was high, with a uniformly shallow anterior chamber. She was started on moxifloxacin 0.5% eye drops 4 times per day, natamycin 5% eye drops every hour, amphotericin 0.15% eye drops every hour, atropine 1% eye drops 3 times per day, and tablet itraconazole 100 mg daily. The high IOP did not respond to intravenous mannitol and oral tablet acetazolamide, which were given under supervision. However, no clinical response was seen, and on the third day, a large corneal central perforation was present (Fig. 1). With the diagnosis of keratomycotic malignant glaucoma, she was advised to have urgent therapeutic keratoplasty (TPK), with an extracapsular cataract extraction (ECCE) and posterior chamber wash. After preoperative mannitol, TPK with ECCE was performed. Graft size of 10.5 mm was sutured by using 16 interrupted 10/0 nylon sutures. The posterior capsule was left intact, but no intraocular lens was placed, and 2 peripheral iridotomies (PIs) were performed at 2 and 10 o’clock positions. Postoperatively, her pressures were controlled on timolol 0.5% eye drops 2 times daily, with a formed anterior chamber for the first 2 days. However, on the third postoperative day, there was a recurrence of extremely high nonresponsive IOP with a flat anterior chamber (Fig. 2). Both PIs were open. The Seidel test was negative. Ultrasound B-scan revealed fluid pockets in the vitreous cavity, suggestive of an aqueous misdirection. She was operated on by using limited pars plana vitrectomy. The anterior chamber was also reformed with basal salt solution, and a gentle goniosynechiolysis was performed. At the last 3-month Received for publication September 29, 2006; revision received February 11, 2007; accepted March 11, 2007. From the *Department of Cornea and External Diseases, †Department of Retina, Aditya Jyot Eye Hospital Pvt Ltd, Wadala, Mumbai, India; and ‡Department of Ophthalmic and Facial Plastic Surgery, Orbital Diseases, and Ocular Oncology. Supported by Aditya Jyot Research Foundation, Dadar, Mumbai, India. The authors state that they do not have any proprietary interest in the products named in this article. Reprints: Vandana Jain, Department of Cornea and External Diseases, Aditya Jyot Eye Hospital Pvt Ltd, Plot No. 153, Road No. 9, Major Parmeshwaran Road, Wadala, Mumbai 400031, India (e-mail: docvandanajain@ rediffmail.com). Copyright Ó 2007 by Lippincott Williams & Wilkins 762 Cornea  Volume 26, Number 6, July 2007