Aspergillus fumigatus keratitis with wreath pattern infiltrates

PURPOSE

To report a case of Aspergillus fumigatus keratitis with clinical features simulating Nocardia keratitis and to highlight the utility of microbiologic investigation in the successful management of infectious keratitis.

METHOD

Case report.

RESULTS

A 62-year-old man presented with complaints of pain, redness, and watering of 10 days' duration in his right eye. Direct microscopic observation of smears of corneal scrapings revealed a fungal etiology. The patient was treated with 5% natamycin eye drops and 1% atropine sulphate eye drops and was advised to visit the hospital for observation. During his visit to the hospital on day 10 after medication, the eye demonstrated a wreath pattern corneal infiltrate that simulated Nocardia keratitis. The fungus grown from culture of corneal scraping was identified as A. fumigatus.

CONCLUSION

This report highlights the significance of subjecting corneal scrapings from suspected cases of infectious keratitis to microbiologic evaluation and emphasizes the fact that a complete microbiologic work-up helps in establishing a definitive etiologic diagnosis and initiating specific antimicrobial therapy.

Treatment and outcome of nocardia keratitis

OBJECTIVE

To report our experience in treatment and outcome ofNocardia keratitis.

METHODS

Medical and microbiology records of seven cases of culture-provenNocardia keratitis seen between January 1997 and March 1999 were reviewed retrospectively. In all patients, corneal scrapings were obtained for direct microscopic evaluation and culture. Drug sensitivity was determined by the Kirby-Bauer disk-diffusion method. The minimum inhibitory concentration of ciprofloxacin and amikacin for these isolates was determined by agar dilution method. Response to medical therapy and the end result were analyzed.

RESULTS

By the in vitro Kirby-Bauer disk-diffusion techniques, all isolates were sensitive to amikacin; six of these isolates were sensitive to gentamicin and four were sensitive to ciprofloxacin. The minimum inhibitory concentration (MIC) of amikacin for all isolates by the agar-dilution technique was well below the MIC breakpoint forNocardia resistance, whereas the MIC of ciprofloxacin was above the MIC breakpoint forNocardia resistance. All patients responded to medical therapy. The corneal infection resolved in three patients after treatment with ciprofloxacin, in one patient after fortified gentamicin, and in three patients after fortified amikacin. Outcome details were available for six patients. There was good visual recovery in four patients, with visual acuity of 20/25 or better in three. The cornea of two patients developed nonvascularized scars, and in four patients in whom the infiltrates were peripheral, vascularization was seen.

CONCLUSIONS

Although patients ofNocardia keratitis may respond to other antibiotics, amikacin appears to be a drug of choice. In this small series, when appropriate therapy was initiated,Nocardia keratitis resolved promptly with good visual recovery.

Impact of underuse, overuse, and discretionary use on geographic variation in the use of coronary angiography after acute myocardial infarction

BACKGROUND

Geographic variation in the use of medical procedures has been well documented. However, it is not known whether this variation is due to differences in use when procedures are indicated, discretionary, or contraindicated.

OBJECTIVES

To examine whether use of coronary angiography after acute myocardial infarction (AMI) according to appropriateness criteria varied across geographic regions and whether underuse, overuse, or discretionary use accounted for variation in overall use.

DESIGN

Retrospective cohort study using data from the Cooperative Cardiovascular Project.

SETTING

Ninety-five hospital referral regions.

PATIENTS

There were 44,294 Medicare patients hospitalized with AMI during 1994 or 1995, classified according to appropriateness for angiography.

MAIN OUTCOME MEASURE

Variation in use of angiography, as measured by the difference between high and low rates of use across regions.

RESULTS

Across regions, variation in the use of angiography was similar for indications judged necessary; appropriate, but not necessary; or uncertain. Variation was lowest for indications judged unsuitable (difference between high rate and low rate across regions = 16.3%; 95% CI = 12.6%; 20.6%). The primary cause of variation in the overall rate of angiography was due to use for indications judged appropriate, but not necessary or uncertain. When variation associated with these indications was accounted for, the difference between the resulting high and low overall rates was 10.8% (9.4%, 12.4%). In contrast, variation in the overall rate remained high when underuse in necessary situations or overuse in unsuitable situations was accounted for.

CONCLUSIONS

Across regions, practice was more similar for patients categorized unsuitable for angiography than for patients with other indications. Variation in overall use of angiography appeared to be driven by utilization for discretionary indications rather than by underuse or overuse. If equivalent rates across geographic areas are judged desirable, then greater effort must be directed toward defining care for patients with discretionary indications.

Atypical Herpes simplex keratitis (HSK) presenting as a perforated corneal ulcer with a large infiltrate in a contact lens wearer: multinucleated giant cells in the Giemsa smear offered a clue to the diagnosis

PURPOSE

To report a case of atypical herpes simplex keratitis initially diagnosed as bacterial keratitis, in a contact lens wearer.

RESULTS

Case report of an 18-year-old woman using contact lenses who presented with pain, redness and gradual decrease in vision in the right eye. Examination revealed a paracentral large stromal infiltrate with a central 2-mm perforation. Corneal and conjunctival scrapings were collected for microbiological investigations. Corneal tissue was obtained following penetrating keratoplasty. Corneal scraping revealed no microorganisms. Giemsa stained smear showed multinucleated giant cells. Conjunctival, corneal scrapings and tissue were positive for herpes simplex virus - 1 (HSV) antigen. Corneal tissue was positive for HSV DNA by PCR.

CONCLUSIONS

Atypical HSV keratitis can occur in contact lens wearers. A simple investigation like Giemsa stain may offer a clue to the diagnosis.

Reproducibility of in vivo brain measures of 5-HT2A receptors with PET and

The test/retest reproducibility of brain measures of 5-HT2A receptors with positron emission tomography (PET) and [18F]deuteroaltanserin was examined in a group of eight healthy human subjects. PET measures of 5-HT2A receptors were obtained under an equilibrium paradigm, with a 40-min PET acquisition starting approximately at 300 min (308+/-11 min) after bolus plus constant infusion of the radiotracer. Three brain outcome measures were obtained at equilibrium, V(3) (ratio of specific brain uptake to free parent plasma concentration of radiotracer), V(3)' (ratio of specific brain uptake to total parent plasma concentration) and RT (ratio of specific to non-displaceable brain uptakes). V(3)' and RT had high test/retest reproducibility, as measured by mean intra-subject% change for cortical brain areas of 14.1 and 11.0%, respectively. They also had high reliability, as measured by mean intra-class correlation coefficients (ICC) for cortical brain areas of 0.86 and 0.88, respectively. V(3) had low test/retest reproducibility, due to high variability in the measures of free parent tracer in plasma. This study supports the feasibility of equilibrium imaging of 5-HT2A receptors with PET and [18F]deuteroaltanserin. The equilibrium imaging method with [18F]deuteroaltanserin allows a single acquisition and blood measurement to provide an image whose pixel values equal a receptor volume of distribution. Since the single image pixel values are proportional to receptor densities, the images can be used in pixel-by-pixel statistical methods, such as SPM, to assess the distribution and density of 5-HT2A receptors in neuropsychiatric disorders.

Comparison of [(18)F]altanserin and [(18)F]deuteroaltanserin for PET imaging of serotonin(2A) receptors in baboon brain: pharmacological studies

The regional distribution in brain, distribution volumes, and pharmacological specificity of the PET 5-HT(2A) receptor radiotracer [(18)F]deuteroaltanserin were evaluated and compared to those of its non-deuterated derivative [(18)F]altanserin. Both radiotracers were administered to baboons by bolus plus constant infusion and PET images were acquired up to 8 h. The time-activity curves for both tracers stabilized between 4 and 6 h. The ratio of total and free parent to metabolites was not significantly different between radiotracers; nevertheless, total cortical R(T) (equilibrium ratio of specific to nondisplaceable brain uptake) was significantly higher (34-78%) for [(18)F]deuteroaltanserin than for [(18)F]altanserin. In contrast, the binding potential (Bmax/K(D)) was similar between radiotracers. [(18)F]Deuteroaltanserin cortical activity was displaced by the 5-HT(2A) receptor antagonist SR 46349B but was not altered by changes in endogenous 5-HT induced by fenfluramine. These findings suggest that [(18)F]deuteroaltanserin is essentially equivalent to [(18)F]altanserin for 5-HT(2A) receptor imaging in the baboon.

Ocular nocardia infections with special emphasis on the cornea

Nocardia are aerobic, gram-positive, nonmotile and branching filamentous bacteria. Corneal infection by Nocardia is rare. Trauma is the most common predisposing factor. Isolated case reports of nocardial infection associated with contact lens wear and laser in situ keratomileusis (LASIK) have been reported. The clinical picture usually consists of superficial patchy infiltrates, which may be arranged in a wreath pattern. Presence of gram-positive, branching, beaded filaments that stain with 1% acid-fast stain (using 1% sulfuric acid, modified Kinyoun's method) in smears of corneal scrapings is suggestive of nocardial infection. Nocardia grow on commonly used media as tiny, white, dry colonies. Available knowledge and clinical experience suggest that although sulfacetamide eyedrops can be tried as the initial drug, trimethoprim-sulfamethoxazole and amikacin are effective drugs. Once therapy is initiated, the infiltrate responds promptly and resolves, forming a corneal scar with or without vascularization, and good visual recovery can be expected.

Epithelial infectious crystalline keratopathy

PURPOSE

To report 2 cases of epithelial infectious crystalline keratopathy.

METHODS

Two patients (2 eyes) with significant meibomitis presented with minimal inflammation and plaque-like lesions on the corneal surface made of fine crystalline structures. Corneal scrapings of these lesions were performed for microbiological evaluation. The patients were treated with topical ciprofloxacin and artificial tears.

RESULTS

Smear examination of the corneal scrapings revealed numerous bacteria and keratinized epithelial cells with no inflammatory cells. Culture showed a significant growth of Staphylococcus epidermidis and Corynebacterium species in the first case and Pseudomonas aeroginosa in the second case. The response to treatment was poor, with recurrence of the crystalline lesion.

CONCLUSION

Infectious crystalline keratopathy lesions may involve the epithelium and occur on the corneal surface.

Implantation malignancy after laparoscopic cholecystectomy

Laparoscopic cholecystectomy may result in spillage of gall bladder contents during dissection or delivery of gall bladder through the umbilical port. We report a 50-year-old man who underwent laparoscopic cholecystectomy for suspected calculous cholecystitis. Histology showed a single focus of adenocarcinoma in the gall bladder. There was spillage of gall bladder contents at the umbilical port during delivery. Six months later, he developed adenocarcinoma at the port site. This was treated by wide excision.

Bilateral infectious keratitis after laser in situ keratomileusis: a case report and review of the literature

OBJECTIVE

To report a case of bilateral infectious keratitis after simultaneous bilateral laser in situ keratomileusis (LASIK) and to explore appropriate preventive, diagnostic, and therapeutic measures.

DESIGN

Interventional case report and literature review.

INTERVENTION

A 22-year-old woman had bilateral corneal infiltrates after simultaneous bilateral LASIK. The same set of instruments was used for surgery on both eyes. Corneal scrapings from the edge of the infiltrate and underneath the flap were taken for microscopic examination and inoculation on culture media. Treatment consisted of irrigation of stromal bed with amikacin sulphate (2.5%) solution along with half hourly instillation of amikacin (2.5%) and cefazolin (5%) eye drops.

MAIN OUTCOME MEASURES

Causative organism and response to medical treatment.

RESULTS

Culture revealed a significant growth of Mycobacterium chelonae from the corneal scrapings of both eyes. There was progressive thinning of corneal stroma in the right eye requiring cyanoacrylate tissue adhesive application. The left eye showed progressive worsening after initial response and required penetrating keratoplasty.

CONCLUSIONS

The risk of bilateral sight-threatening complications must be kept in mind when contemplating bilateral simultaneous LASIK. Nontuberculous mycobacteria should be considered as an etiologic agent in cases of infectious keratitis occurring after LASIK. Microbiology work-up of a specimen collected directly from the site of lesion can help in early diagnosis and institution of appropriate therapy.

Keratocyte loss in Acanthamoeba keratitis: phagocytosis, necrosis or apoptosis?

PURPOSE

Pathogenesis of Acanthamoeba keratitis involves breakdown of epithelial barrier, stromal invasion by Acanthamoeba, loss of keratocytes, inflammatory response and finally stromal necrosis. The loss of keratocytes, believed to be due to the phagocytic activity of the parasite, occurs disproportionate to and independent of the parasite load, thereby suggesting additional modes of cell loss. To test our hypothesis that the loss of keratocytes in Acanthamoeba keratitis is due to apoptosis, we did both histology and histochemistry on the corneal tissues.

METHODS

Routine Haematoxylin and Eosin, Gomori's Methenamine Silver and Periodic acid Schiff stained sections of five corneal tissues from penetrating keratoplasty and eviscerated eyes were reviewed. TUNEL staining was done for morphological detection of apoptosis in three cases, using formalin-fixed, paraffin-processed tissues.

RESULTS

Histological changes were epithelial ulceration, loss of keratocytes in all layers, inflammation in anterior two-thirds of the stroma with necrosis, and deeper quiet stroma. Acanthamoeba trophozoites were found in the anterior stroma while the cysts were more in the deeper stroma, with minimal or no inflammatory response. TUNEL staining was positive in keratocytic nuclei in all layers.

CONCLUSIONS

This study demonstrates that one of the modes of keratocyte loss in Acanthamoeba keratitis is by apoptosis, possibly in addition to the necrotic process and phagocytic activity of the parasite. The death of inflammatory cells also appears to be mediated by apoptosis.

Emergence of Vibrio cholerae O1 biotype El Tor serotype Inaba from the prevailing O1 Ogawa serotype strains in India

The toxigenic Inaba serotype of Vibrio cholerae O1 biotype El Tor reappeared in India in 1998 and 1999, almost 10 years after its last dominance in Calcutta in 1989. Extensive molecular characterization by ribotyping, restriction fragment length polymorphism, and pulsed-field gel electrophoresis indicated that recent Inaba strains are remarkably different from the earlier Inaba strains but are very similar to the prevailing V. cholerae O1 Ogawa El Tor biotype strains. The antibiograms of the Inaba strains were also similar to those of the recent V. cholerae Ogawa strains. These V. cholerae O1 Inaba strains appear to have evolved from the currently prevailing Ogawa strains and are likely to dominate in the coming years.

Patient characteristics, diagnosis, and treatment of non-contact lens related Acanthamoeba keratitis

AIM

To review the clinical characteristics, diagnosis, and visual outcome in patients with non-contact lens related Acanthamoeba keratitis and compare the findings with reported series of contact lens associated Acanthamoeba keratitis.

METHODS

Medical and microbiology records of 39 consecutive patients with a diagnosis of Acanthamoeba keratitis, at a tertiary eyecare centre in India between January 1996 and June 1998, were analysed retrospectively.

RESULTS

A majority of the patients presented with poor visual acuity and large corneal stromal infiltrates (mean size 38.20 (SD 26. 18) mm). A predisposing factor was elicited in 19/39 (48.7%) patients (trauma 15, dirty water splash three, leaf juice one). None of the patients had worn contact lenses. Most patients (26/39 (66. 6%)) came from a low socioeconomic background. Complaint of severe pain was not a significant feature and radial keratoneuritis was seen in 1/39 (2.5%) patients. A ring infiltrate was present in 41.1% of cases. A clinical diagnosis of fungal keratitis was made in 45% of the patients before they were seen by us. However, all patients were diagnosed microbiologically at our institute based on demonstration of Acanthamoeba cysts in corneal scrapings (34/39) and/or culture of Acanthamoeba (34/39). Treatment with biguanides (PHMB, 15/38 (39.4%), PHMB with CHx, 23/38 (60.5%), one patient did not return for treatment) resulted in healing with scar formation in 27 out of 31(87.0%) followed up patients (mean time to healing 106.9 days). Overall visual outcome was poor with no statistical difference between cases diagnosed within 30 days (early) or 30 days after (late) start of symptoms. The visual outcome in cases requiring tissue adhesive (five) and keratoplasty (three) was also poor.

CONCLUSIONS

This is thought to be the largest series of cases of Acanthamoeba keratitis in non-contact lens wearers. In such cases, the disease is advanced at presentation in most patients, pathognomonic clinical features are often not seen, disease progression is rapid, and visual outcome is usually poor. Possible existence of Acanthamoeba pathotypes specifically associated with non-contact lens keratitis and unique to certain geographical areas is suggested.

Cluster-analysis & patterns of dissemination of multidrug resistance among clinical strains of Vibrio cholerae in Calcutta, India

BACKGROUND & OBJECTIVES

Antimicrobial resistance among Vibrio cholerae has been monitored for several years in Calcutta. To investigate the changing trends in multidrug resistance (MDR) among different serogroups of V. cholerae and to perform software assisted cluster analysis the current study was undertaken.

METHODS

Strains isolated from patients with cholera and "cholera-like" diarrhoea admitted in the Infectious Diseases Hospital, Calcutta were analysed. Eight hundred and forty V. cholerae strains isolated from 1992 through 1997 were tested for susceptibility to 11 antibiotics. Cluster analysis was done using SPSS software.

RESULTS

Most of the strains exhibited MDR with fluctuating trends as the resistance profile diverged each year. A total of 119 different resistance profiles exhibited by V. cholerae O1, O139 and non-O1, non-O139 serogroups were analysed by cluster combination method. During 1993 and 1994, 53 per cent of V. cholerae O139 and 82 per cent of V. cholerae O1 serogroups, respectively, exhibited maximal number of new resistance patterns. The frequency of new resistance patterns among V. cholerae non-O1, non-O139 was constantly high (33-47%) during 1995 to 1997.

INTERPRETATION & CONCLUSIONS

With a few exceptions, preponderance of the resistance profiles was generally not confined to any serogroup. The cluster analysis depicted dissemination of some of the resistance patterns commonly found among V. cholerae non-O1, non-O139 belonging to different serogroups to the O139 serogroup in the succeeding years. In this study we have shown that the V. cholerae strains are resistant to several antibiotics with constant change in the MDR profiles. It is imperative to define the susceptibility pattern of the strains to determine the effective drug of choice for the treatment of cholera.

Infectious keratitis in climatic droplet keratopathy

PURPOSE

To report the ulcer characteristics, microbiologic data, and outcome of infectious keratitis associated with climatic droplet keratopathy (CDK), suggesting that CDK is a predisposing factor for infectious keratitis.

METHODS

Medical records of 32 patients (34 eyes) in whom infectious keratitis was seen in association with CDK were retrospectively reviewed. Data were collected regarding the nature of CDK lesions, infiltrate characteristics, organisms isolated, and outcome.

RESULTS

CDK was peripheral in 16 (47.1%) eyes, central in 8 (23.5%), and diffuse in 10 (29.4%). The CDK lesions were nodular and elevated in all eyes. The infiltrate was adjacent to the CDK lesions in 28 eyes (82.4%). The infiltrate size (widest dimension) ranged 2-6 mm in 18 eyes (52.9%) and was >6 mm in 7 (20.5%). The infiltrate was full thickness in 15 eyes (44.1%) and was involving up to the middle third of the corneal stroma in another 18 (52.8%). Hypopyon was seen in all. Bacteria were commonly isolated. Staphylococcus epidermidis (six eyes) and Streptococcus pneumoniae (five eyes) were the common bacteria isolated. Resolution with medical treatment was seen in 20 (58.8%) eyes.

CONCLUSIONS

CDK is a predisposing factor for infectious keratitis. Treatment should be considered for advanced and nodular lesions, even if they are peripheral, to prevent infectious keratitis.

Expanding multiple antibiotic resistance among clinical strains of Vibrio cholerae isolated from 1992-7 in Calcutta, India

Antimicrobial susceptibilities of Vibrio cholerae strains isolated from cholera patients admitted to the Infectious Diseases Hospital, Calcutta, India for 6 years were analysed to determine the changing trends; 840 V. cholerae strains isolated in 1992-1997 were included in this study. Among V. cholerae serogoup O1 and O139, ampicillin resistance increased from 1992 (35 and 70%, respectively) to 1997 (both serogroups 100%). Resistance to furazolidone and streptomycin was constantly high among V. cholerae O1 strains with gradual increase in resistance to other drugs such as ciprofloxacin, co-trimoxazole, neomycin and nalidixic acid. V. cholerae O139 strains exhibited susceptibilities to furazolidone and streptomycin comparable with those of O1 strains. However, after initial increase in resistance to chloramphenicol and co-trimoxazole, all the V. cholerae O139 strains became susceptible to these two drugs from 1995 onwards. Both V. cholerae O1 and O139 remained largely susceptible to gentamicin and tetracycline. V. cholerae non-O1, non-O139 strains, in contrast, exhibited high levels of resistance to virtually every class of antimicrobial agents tested in this study especially from 1995. Kruskal-Wallis one-way analysis showed that V. cholerae O1 Ogawa serogroup exhibited significant yearly increase in resistance to nine antibiotics followed by non-O1 non-O139 and O139 strains to six antibiotics and two antibiotics respectively. Interesting observation encountered in this study was the dissipation of some of the resistant patterns commonly found among V. cholerae non-O1 non-O139 or O1 serogroups to the O139 serogroup and vice versa during the succeeding years.

Aspergillus flavus keratitis after laser in situ keratomileusis

PURPOSE

To report a case of fungal keratitis caused by Aspergillus flavus after laser in situ keratomileusis surgery.

METHODS

Case report. A 24-year-old woman developed pain, redness, decreased vision, and an infiltrate posterior to the corneal flap in her right eye 3 days after laser in situ keratomileusis. On referral, approximately 3 weeks after laser in situ keratomileusis, examination of the right eye revealed light perception vision, a large full-thickness corneal infiltrate, and hypopyon. Corneal scrapings were taken for direct microscopic examination and culture.

RESULTS

Corneal scraping revealed the presence of fungal filaments in smears and in culture. The fungus was identified as A. flavus. Intensive topical natamycin and systemic ketoconazole therapy was initiated. Despite intensive medical treatment, the infiltrate progressed and the patient was subjected to a therapeutic penetrating keratoplasty. There was no recurrence of infection after surgery. At last follow-up 4 months after surgery, the eye was quiet with graft edema.

CONCLUSION

Fungal keratitis is a rare complication of laser in situ keratomileusis surgery. In a case that does not respond to medical treatment, early surgical intervention must be considered.

Clinical and microbiological profile of Bacillus keratitis

PURPOSE

To examine the clinical and microbiological profile of Bacillus keratitis.

METHODS

A retrospective review was done of all medical and laboratory records of patients with infectious keratitis in an urban tertiary level eye-care center in South India between January 1991 and June 1997.

RESULTS

Nineteen eyes of 17 patients having microbiologically proven Bacillus keratitis were reviewed. The mean age of the patients was 32.64 years (range, 3-70). The duration of symptoms ranged from 1 day to 3 months, with 11 eyes seen within a week of onset of symptoms. Trauma (five eyes), lagophthalmos (two eyes), topical corticosteroid therapy (one eye), bullous keratopathy (two eyes), previous corneal scars (two eyes), and diabetes (one eye) were identified as predisposing factors. Severe corneal features, disproportionate to the duration of symptoms, were present in most of the eyes. Gram stain of corneal scrapings showed variably stained bacilli in eight (42.1%) cases. Polymicrobial infection was present in six eyes (two fungal, four bacterial). Of the 16 isolates tested for in vitro antibiotic susceptibility, 100% were sensitive to gentamicin, 15 (93.75%) were sensitive to ciprofloxacin and norfloxacin, 14 (87.5%) were sensitive to chloramphenicol, and 10 (62.5%) were sensitive to cefazolin. Whereas 12 (63.1%) eyes required only medical therapy, adjunctive procedures were required in seven (36.8%) eyes. The ulcers healed (mean time to healing, 37.4+/-28.6 days) in 16 eyes (lost to follow-up, three). Visual acuity had improved after treatment in 10 (71.4%) of 14 eyes in whom vision could be recorded.

CONCLUSION

Bacillus is an unusual pathogen in the clinical setting of infectious keratitis. The infection is mostly amenable to treatment with commonly used antibiotics, and the final outcome is often satisfactory.

Fungal keratitis after laser in situ keratomileusis

A 22-year-old woman presented with pain, redness, watering, and decrease in vision in her left eye 15 days after laser in situ keratomileusis for myopia. Slitlamp examination showed a central full-thickness infiltrate with hyphate edges. Microscopic examination of corneal scrapings from the edge and underneath the flap showed fungal filaments, and the growth on culture media was identified as Scedosporium apiospermum.

Keratomycosis: clinical and microbiologic experience with dematiaceous fungi

OBJECTIVE

To assess the significance of dematiaceous fungi in the causation of keratomycosis.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Eighty-eight cases of dematiaceous fungal keratitis seen at the L. V. Prasad Eye Institute, Hyderabad, India from January 1991 through December 1996.

INTERVENTION

Only culture-proven cases were analyzed.

MAIN OUTCOME MEASURES

Predisposing factors, clinical characteristics, microbiology, treatment methods, and outcome.

RESULTS

Of 557 cases of fungal keratitis seen during the study period, dematiaceous fungi were the etiologic agents in 88 (15.7%), after Fusarium in 210 (37.6%) and Aspergillus species in 170 cases (30.4%), respectively. Trauma was the most common predisposing factor (47.7%). Fifty-three eyes (61.3%) had the classical clinical picture of yellow-white, dry raised infiltrate with feathery hyphate edges at initial examination. The characteristic macroscopic pigmentation was seen in only 24 eyes (27.27%). Septate branching fungal filaments were identified in 78 smears (88.63%) on light microscopy, of which 5 (5.7%) also showed the presence of bacteria. Curvularia species dominated the spectrum (22.7%). Treatment was started in 48 eyes with topical antifungal agents, whereas 37 received both oral and topical antifungal agents. Outcome data were available for 68 cases. Forty-nine (72%) responded to medical therapy, whereas 13 eyes required therapeutic penetrating keratoplasty and 6 eyes had to be eviscerated.

CONCLUSIONS

This is the largest series of keratitis caused by dematiaceous fungi reported to date. It clearly brings out the clinical importance of this group of corneal infections.