Challenges in the management of microsporidial keratoconjunctivitis: recurrent infection and environmental contamination

A young male, a known steroid responder with vernal keratoconjunctivitis, presented with diminished vision, redness and foreign body sensation in his left eye for 20 days. He was on anti-glaucoma medications and tacrolimus 0.03% eye ointment. On examination, greyish-white coarse lesions were observed on his left cornea, along with a few medium to large keratic precipitates (KPs). The corneal scraping demonstrated microsporidial spores, and 2 hourly lubricating eyedrops were initiated. Three days later, the patient remained symptomatic; therefore, a 4 hourly dose of loteprednol 0.5% was initiated, which led to the resolution of KPs. At the 5 weeks follow-up, a few similar coarse lesions were noted on the right cornea. Due to the persistent and recurrent nature of the disease, repeated exposure to a contaminated water source was suspected. Analysis of well water from the patient's home showed microsporidia through conventional PCR. On refraining from washing his eyes with this water, the patient's symptoms and epithelial lesions reduced in both eyes over 6 weeks.