Medical Care
Keratitis
Actinomycetes are usually susceptible to penicillins and cephalosporins. [39, 40, 41, 42] The treatment of keratoactinomycosis used to be excision of necrotic tissue, followed by cauterization. However, good results have been obtained by subconjunctival penicillin coadministered with systemic iodides. Alternatively, topical sulfacetamide or penicillin can be used.
Canaliculitis
Actinomycetes are usually susceptible to penicillins and cephalosporins. Postoperatively, patients may be treated with topical cefazolin for 1 month. Adjunctive hyperbaric oxygen therapy for actinomycotic lacrimal canaliculitis has been reported. [43]
Endophthalmitis
Intraocular, periocular, topical, and systemic therapy.
Surgical Care
Keratitis
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All reported cases of keratoactinomycosis responded to therapy, which included intraocular, topical, and systemic antibiotics, as well as pars plana vitrectomy and partial iridectomy.
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Urgent keratoplasty for a corneal infection by Actinomyces species was reported in a 41-year-old man.
Canaliculitis
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A 2-snip punctoplasty, cast removal, curettage, probing, and adjunctive antibiotic therapy usually result in resolution of the canaliculitis.
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Lee et al in 2009 presented a 1-snip punctoplasty and canalicular curettage. The affected punctum is incised along the posterior wall vertically. A chalazion curette is inserted into the canaliculus, and the concretions are evacuated. [44]
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Cultivation of the surgically obtained dacryoliths and secretion enables reliable proof of Actinomyces and allows for an appropriate therapy for canaliculitis. Even though Actinomyces species are sensitive to penicillin, cure of canaliculitis does not occur until all the concretions and the granulations that are present in the canaliculus are meticulously removed.
Endophthalmitis
A diagnostic and therapeutic, 3-port, pars plana vitrectomy may be performed in cases where a diagnosis has not been achieved. [25]
Consultations
An external disease and cornea specialist may provide care for the anterior segment.
An oculoplastics consult may be required for eyelid and orbital involvement.
A posterior segment surgeon is necessary for endophthalmitis.
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Canaliculitis of the left lower lid. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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Canaliculitis of the right upper lid. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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A pediatric patient with canaliculitis. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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A patient presenting with pseudocanaliculitis secondary to a chalazion. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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A patient presenting with pseudocanaliculitis secondary to a chalazion. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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Actinomyces israelii (non–spore-forming, gram-positive bacilli). Courtesy of Medical Education Information Center, Department of Pathology and Laboratory Medicine, The University of Texas-Houston Medical School.
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Actinomyces israelii. (The image is labeled.)
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Actinomycosis.
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Clinical slit-lamp photographs of Actinomyces infectious crystalline keratopathy (A) upon initial presentation, (B) immediately following first repeat penetrating keratoplasty, and (C and D) low and high magnification of recurrent corneal opacities 6 months later. White arrows highlight temporal opacity within host cornea.
