PMC9729021_01
Timeline of history of present illness. Graphical representation of the ocular and systemic disease course for this patient.
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fig1
He was fitted with scleral lenses (Boston Sight) in both eyes to improve his vision and support his fragile ocular surface.  Figure 1 outlines a timeline of his ophthalmic disease course. The likelihood of a gram-positive organism was reinforced when on further history; the patient reported that he was with his grandchild who had strep throat a few days prior to onset of symptoms (Figure 1).
Slit-lamp photograph of the right eye at initial presentation. (a) A slit-beam photograph centered over the new crystalline pattern of branching thin structures in the anterior stroma. (b) A wide-beam photograph demonstrating the branch-like structures in the anterior stroma of the central visual axis (arrowhead), and nasally, a preexisting triangular anterior stromal scar (dashed outline). (c) Confocal microscopy revealed mid-stromal (195 mum deep) highly reflective needle-like structures consistent with crystalline keratopathy, but not specific for an individual pathogen.
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Examination of the right cornea (Figure 2(a)) demonstrated a stable preexisting triangular 1.5 mm anterior stromal haze paracentrally and a new crystalline pattern of branching thin structures in the anterior stroma centrally, and keratic precipitates in the endothelium (Figure 2(b)). Confocal microscopy revealed hyperreflective needle-like structures located in the mid stroma at approximately 195 mum consistent with crystalline keratopathy, but nonspecific for an individual pathogen (Figure 2(c)).
Image series from surgical video demonstrating the intrastromal antibiotic injections through a 30-gauge needle. The injections were made in a circular pattern surrounding the crystalline deposits, achieving a higher concentration centrally and keeping the needle tracks away from the visual axis (image progression from (a) to (f)). Full video available here in https://www.dropbox.com/s/x0gbutn8d64a5sd/Video1.mp4?dl=0.
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This sequence created a higher concentration centrally and kept the needle tracks away from the visual axis (Figure 3).
Slit-lamp photograph of the right eye 23 months after initial presentation. The "branch-like" infiltrates were still visible centrally (solid outline). Multiple linear needle tracks from the intrastromal injections were in the paracentral cornea stroma (arrowheads). The triangular 1.5 mm anterior stromal haze was stable in appearance (dashed outline).
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fig4
The appearance of the branch like structures was mostly stable with slightly less defined borders without any further increase in size (Figure 4).