to report an unusual case of multifocal bacterial keratitis that despite success - ful treatment caused chronic ocular hypertension . a 67-year - old woman with unilateral multifocal keratitis and no previous ocular pathology was admitted to our hospital . corneal scrapings and conjunctival samples were obtained for culture and the patient received intensive therapy with fortified vancomycin and tobramycin eye drops . the cultures demonstrated two strains of staphylococcus epidermidis , one resistant to ciprofloxacin and both sensitive to vancomycin . treatment was effective and gradually discontinued after total cessation of the inflammatory activity . during the follow - up period , the patient developed late and persistent ocular hypertension of unknown etiology , in absence of any detectable inflammation or complication , and received permanent antiglaucoma therapy . patients with multifocal bacterial keratitis may need intraocular pressure monitoring , even after complete infection healing . staphylococcus is a common gram - positive bacterium causing keratitis that tends to present with a focal and well - defined white or yellow - white infiltrate . during the infection , corneal inflammation can lead to neovascularization and scarring , while internal ocular inflammation can cause synechia formation , elevated intraocular pressure and cataract [ 1 , 2 ] . several staphylococcal strains have been reported resistant to topical quinolone therapy [ 3 , 4 ] . we report an unusual case of quinolone - resistant multifocal staphylococcal keratitis without a history of previous ocular pathology , which caused chronic intraocular pressure elevation despite successful keratitis treatment and complete resolution of external and internal ocular inflammation . a 67-year - old woman presented in the emergency section of our department with gradual onset of redness , tearing , photophobia and a 4-day history of blurred vision in her right eye . there was no history of contact lens wear , previous ocular disease , trauma or surgery . examination of the right eye revealed visual acuity of counting fingers , intense conjunctival injection , mild corneal edema and three corneal ulcers of different extension ( 15 mm in diameter ) . a moderate aqueous flare was noted in the anterior chamber without presence of hypopyon or pupillary synechiae ( fig . 1 ) . intraocular pressure and fundus were normal , and there were no pathological findings in her left eye . corneal scrapings and conjunctival samples were obtained from the right eye and sent to the laboratory for culture . the patient was hospitalized and received empirical treatment with fortified vancomycin + tobramycin ( voncon , lilly + tobrex , alcon ) eye drops every 30 min the first day , every hour the second day and afterwards every 2 h. topical cyclopentolate ( cyclogyl , alcon ) 3 times daily was also administered . the cultures demonstrated the presence of two strains of coagulase - negative staphylococcus epidermidis , one resistant to ciprofloxacin and both sensitive to vancomycin . one week after treatment implementation , the patient reported partial relief from her initial symptoms . a considerable reduction of the extension of corneal ulcers was noted , though aqueous flare and intraocular pressure increased ( 32 mm hg ) and corneal neovascularization appeared at the limbus adjacent to the corneal ulcers . treatment was modified to topical vancomycin , dexamethasone ( maxidex , alcon ) and cyclopentolate initially 3 times daily , with a progressive tapering scheme during the following 3 weeks . after the 3-week - period , the corneal ulcers were completely healed ; there was no conjunctival injection , no visible aqueous flare but only a mild scarring at the superior limbus ( fig . two months later , a persistent ocular hypertension ( 2628 mm hg ) of unknown etiology and without any external or internal ocular inflammation was noted in the right eye at three consecutive visits . a goldmann contact lens was used to perform a 360 gonioscopy that did not reveal any pathological findings . intraocular pressure was normal in the left eye and corneal pachymetry was normal in both eyes . topical brinzolamide was restarted and follow - up was continued monthly . for the next 6 months , intraocular pressure in the right eye fluctuated within normal limits and no inflammatory recurrence was observed . occasionally , staphylococcal keratitis can present with predominantly multifocal epithelial infiltration , especially in the setting of hydrophilic contact lens wear or after laser in situ keratomileusis . multiple foci of abscesses resemble fungal satellite lesions [ 1 , 5 ] . in the present case , furthermore , we did not detect any predisposing factors for chronic intraocular pressure elevation , such as history of glaucoma or ocular hypertension , trauma , relapsing inflammation and anterior or posterior synechiae . the existence of aqueous flare in the anterior chamber could explain the temporary intraocular pressure rise diagnosed in the second week , though after total cessation of the inflammatory activity the intraocular pressure returned to normal values as expected . steroid - induced ocular hypertension does not seem to be relevant since steroid treatment was of limited duration , low dosed and gradually discontinued . a possible explanation for the late and persistent intraocular pressure elevation may be a permanent damage of the trabecular meshwork caused by staphylococcal toxins . despite normal appearance of the iridocorneal angle on gonioscopy , invisible microscopic changes could not be excluded . the resistance of one s. epidermidis strain to ciprofloxacin is in accordance with previous reports and indicates that microbial culture is necessary in cases of extensive bacterial corneal ulcers [ 3 , 4 ] . furthermore , it also shows that an initial empirical treatment with a combination of fortified topical antibiotics may be superior to topical quinolone monotherapy in these cases . however , further evidence is required to support the above hypothesis since there are studies showing equivalence of fluoroquinolone monotherapy to fortified medications in microbial keratitis [ 6 , 7 ] . unfortunately , it was not possible for our laboratory to test the sensitivity of the ciprofloxacin - resistant strain to newer - generation quinolones , which could have had better activity against these gram - positive organisms . in conclusion , the present case demonstrates that in patients with multifocal keratitis , differential diagnosis between fungal and bacterial infection is critical for successful treatment . besides treatment , patient follow - up and intraocular pressure monitoring may be needed , even after complete infection healing and resolution of inflammatory signs .
purposeto report an unusual case of multifocal bacterial keratitis that despite success - ful treatment caused chronic ocular hypertension.methodsa 67-year - old woman with unilateral multifocal keratitis and no previous ocular pathology was admitted to our hospital . 
 corneal scrapings and conjunctival samples were obtained for culture and the patient received intensive therapy with fortified vancomycin and tobramycin eye drops.resultsthe cultures demonstrated two strains of staphylococcus epidermidis , one resistant to ciprofloxacin and both sensitive to vancomycin . 
 treatment was effective and gradually discontinued after total cessation of the inflammatory activity . during the follow - up period , 
 the patient developed late and persistent ocular hypertension of unknown etiology , in absence of any detectable inflammation or complication , and received permanent antiglaucoma therapy.conclusiondifferential diagnosis between fungal and bacterial infection is critical in cases of multifocal keratitis . 
 patients with multifocal bacterial keratitis may need intraocular pressure monitoring , even after complete infection healing .