PMC8006453_01
Photographs of the progression of a refractory fungal stromal abscess of the right eye in an 11-year-old female alpaca on day 1 (A), day 2 (B), day 3 (C), and day 7 (D). (A)-Day 1, on presentation, there is approximately a 5 mm paraxial stromal abscess with a yellow creamy appearance and fluffy borders, pinpoint satellite lesions in the adjacent stroma (unable to appreciate in photo), marked geographical corneal edema, and dense stromal corneal vascularization. Photo obtained prior to application of fluorescein stain. (B)-By day 2, a satellite lesion adjacent to the stromal abscess had substantially increased in size by roughly 3 mm and the multiple small corneal bullae had worsened/coalesced to become a large corneal bulla overlying the medial aspect of the lesion with fluorescein stain uptake. (C)-By day 3, despite aggressive medical management the two stromal abscesses had coalesced, the corneal bullae had progressed, and the overlying cornea appeared moderately malacic. Photo obtained prior to use of fluorescein stain; after application it was noted the ulcer had increased in size to cover the whole lesion. Corneal cross linking with the accelerated protocol was performed the following day. (D)-On day 7, the stromal abscess had continued to increase by ~2 mm with improvement in corneal bullae, malacia, and progression of stromal vascularization. Fluorescein staining is evident overlying a portion of the abscess.
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F1
The conjunctiva was moderately hyperemic, the cornea had a 5 x 6 mm yellow creamy paraxial stromal abscess with fluffy borders, a few surrounding pinpoint satellite lesions in the adjacent stroma, severe corneal edema with secondary bullae, dense stromal vascularization, and several <= 1 mm regions of positive fluorescein uptake overlying the abscess (Figure 1A). On day 2, a satellite lesion adjacent to the stromal abscess had substantially increased in size by roughly 3 mm, the corneal bullae had worsened, and the pupil remained miotic (Figure 1B); therefore, the frequency of voriconazole and atropine was increased to q2h and q8h, respectively. On day 3, despite aggressive medical management, the two stromal abscesses had coalesced, the corneal bullae had worsened, the overlying cornea appeared malacic, and the epithelial defect had increased in size to nearly cover the entire abscess (Figure 1C). However, the corneal stromal abscess continued to increase in size another 2 mm by day 7 (Figure 1D).
Photographs of the right eye of an 11-year-old female alpaca post-operatively after penetrating keratoplasty for a fungal stromal abscess immediately after surgery (A) and 4 weeks after surgery (B). (A)-A 3 mm 4 ply porcine small intestinal submucosa graft (Vetrix Plus) was placed within the penetrating keratoplasty site with an 11 x 9 mm island conjunctival graft overlying the lamellar keratectomy site of 50% stromal depth, sutured in place with 8-0 polyglactin 910 suture. (B)-The eye was visual and comfortable 4 weeks after surgery with a healthy island conjunctival graft, sutures intact but dissolving, and a dilated pupil.
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F2
All corneal and graft sutures were performed with 8-0 polyglactin 910 suture (Figure 2A). The dense stromal vascularization had regressed, the island graft was pink and healthy, sutures remained intact but dissolving, and the surrounding corneal edema had resolved (Figure 2B).
Timeline of the alpaca's clinical course and treatments. Black stars indicate specific treatments and results. Day 4: Corneal cross-linking performed and subconjunctival injection of 0.5 ml voriconazole 1%. Day 9: Culture growth of Scopulariopsis brevicaulis. Day 10: Surgical lamellar keratectomy, penetrating keratoplasty, and island conjunctival graft. Day 11: Parenteral ceftiofur crystalline-free acid once. Day 20: Culture growth of Fusarium verticillioides. Day 37: Recheck at ISU-considered healed. Day 51: Recheck with rDVM-no relapse off medication. Day 375: Telephone and photo updates with owners and rDVM-small scar, no concerns. Details about the products and dosages can be found in the main text.   = pantoprazole (yellow bar).
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F3
A complete treatment timeline is provided (Figure 3).