What may lie beneath!

Pigmented filamentous lesions were seen on the underside of an ocular prosthesis being worn by a child with post-enucleation anophthalmic socket. Culture and staining revealed it to be Aspergillus flavus. This unexpected detection of fungus in a prosthetic eye makes us wonder what all may lie on the blind side of the prosthesis.

Prosthesis use in ophthalmology may be secondary to an anophthalmic socket following enucleation or evisceration. The prosthesis can be prefabricated (stock shell) or custom fit. The most frequent complaint of the patients using eye prosthesis is discharge. These complaints are more commonly seen in patients using a stock shell than a custom fit prosthesis, the reason being a more snug fit of a custom fit prosthesis and obliteration of the dead space which causes pooling of secretions.

A five-year-old healthy child from a lower socioeconomic stratum, presented to us for a custom fit prosthesis. Her right eye had been enucleated, with a non-porous implant, three years back for a disorganized globe. Following surgery the child was doing well with no history of socket infection. She had been wearing a stock shell for the past three years. The mother complained of occasional discharge for which topical antibiotic drops were instilled off and on. The mother was removing the prosthesis occasionally (once in two months), and reinserting it after cleaning with warm water. No antibiotic drops were being used at the time of examination. On examining the stock shell after removal, pigmented filaments were seen on the underside (Fig. 1). The socket examination was unremarkable. Lacrimal syringing was patent. Staining and culture of the filaments revealed it to be Aspergillus flavus (Figure 2, Figure 3). The conjunctiva culture was negative for fungal and bacterial growth. There was no evidence of systemic mycosis.

Figure 1

Underside of an ocular prosthesis showing pigmented filamentous growth.

Figure 2

Green coloured colony of Aspergillus flavus.

Figure 3

Aspergillus flavus – phialides radiating from the vesicle in all directions.

Comment

The increase in prevalence of bacterial infection, especially gram negative bacteria, in anophthalmic sockets has been reported. Fungal flora has been reported to be similar to the normal fellow eye. Another study has however commented on increase in fungal isolation from anophthalmic socket as compared to the normal eye (fungus growth in 12 out of 74 cases and both bacteria and fungus in 6 out of 74 cases).

With these two conflicting reports in the literature, it is not clear whether or not fungal flora of an anophthalmic socket is different from normal conjunctiva flora. Literature search for fungus isolated from prosthesis per se was negative.

No study has described fungal growth on eye prosthesis.

We report this unexpected detection of fungus in a prosthetic eye to increase awareness for the examination of not only the anophthalmic socket but also the prosthetic eye, as the underside of the prosthesis may act as a nidus for infection.

Conflict of interest

The authors declare that there is no conflict of interest.