Microbial keratitis and its management at a rural centre: achieving success with limited resources

PURPOSE

Microbial keratitis is a sight-threatening condition with a higher incidence in agrarian populations. In countries with a high indigent population, due to financial and other constraints, patients prefer to seek therapy locally rather than travel to advanced centres. The aim of this study is to describe the epidemiology, clinical characteristics, and outcomes of 60 consecutive patients with microbial keratitis managed at a rural centre.

METHODS

Descriptive case series. All patients clinically diagnosed with infectious keratitis were included. Corneal scrapings were obtained and microbiological identification was done by Gram stain. Anti-microbial therapy was commenced based on smear findings and the patients were followed up till disease resolution.

RESULTS

Sixty eyes of 60 patients were diagnosed with microbial keratitis in the study period. The mean age was 47.43 ± 18.69 years. Male:female ratio was 47:53. Risk factors included ocular trauma in the majority of patients (46/60; 76.7%). Microorganisms were identified on 75.6% of smears, with fungal filaments (65.4%) being the most common. Ulcers were central in over half (32/60; 53.3%), and > 3 mm in diameter in over three-fourths (81.6%) of patients. Forty-four patients (73.3%) achieved treatment success whereas 16/60 (26.6%) required referral to our tertiary-eye care facility for management. The median time to resolution was 14 days (IQR 10-26 days).

CONCLUSION

Our series demonstrates the feasibility of microbiology-guided therapy in microbial keratitis by ophthalmologists at the secondary rural eye-care level. Two-thirds of the patients could be successfully managed at the rural centre and only severe cases needed a referral to tertiary centres.

Clinical differentiation of keratitis due to fungus and Pythium: A photographic survey

Purpose

To evaluate the knowledge and skills of clinicians in differentiating cases of Pythium from fungal keratitis based on their clinical appearance.

Methods

Thirty slit-lamp photographs from culture-proven cases of Pythium and fungal keratitis were selected for conducting a prospective online-based photographic survey. The participants were asked to identify the causative organism and enlist the specific clinical features which helped in reaching the diagnosis. Both cornea specialists and clinical fellows/trainees participated in the survey. Sensitivity, specificity, and predictive values were estimated, and the factors associated with these, including the identification rates of clinical signs, were evaluated using bivariate and multivariate linear regression analyses. The identification rates between the consultants and fellows were compared.

Results

A total of 42 cornea specialists (28 consultants and 14 clinical fellows) participated in the survey. Clinicians were able to differentiate Pythium from fungal etiology in only 56% of cases. The differentiating ability between the consultants and fellows was statistically insignificant. Average sensitivity, specificity, and positive and negative predictive values for differentiating Pythium from fungus were 56%, 65%, 56%, and 66%, respectively. The specific clinical features enlisted by the participants to differentiate Pythium from fungus were the presence of tentacles, peripheral guttering, dot-like infiltrates, and elevated plaques.

Conclusion

Clinical knowledge regarding the signs and symptoms and the microbiological identification of features for Pythium are still lacking among clinicians. As the treatment protocols are distinctly different for both, it is imperative to enhance the knowledge and diagnosing ability to tackle this emerging microorganism which causes high morbidity.

Total Anterior Staphyloma Secondary to Acanthamoeba Keratitis

ABSTRACT

There are very few published cases of total anterior staphyloma, all of which have been reported as secondary to fungal keratitis. This study reports the clinical and histopathological findings and subsequent management of a 27-year-old healthy female patient who developed total anterior staphyloma after poor compliance with treatment for clinically diagnosed acanthamoeba keratitis. She underwent a successful evisceration with good long-term results. This case highlights that total anterior staphyloma may also result from untreated keratitis which is not fungal in origin. In cases of fungal and acanthamoeba keratitis, patient compliance with both treatment and follow-up is paramount to avoid vision-threatening sequelae that present significant challenges in their management.

Rhino-orbital mucormycosis: Our experiences with clinical features and management in a tertiary care center

Objective: To determine the prevalence, risk factors, and elaborate our experiences with diagnosis and treatment of patients with mucormycosis, enabling a better understanding of the disease and its management.

Methods: This is a case series of patients with Covid-19 associated with Rhino-orbital-cerebral mucormycosis, managed in our tertiary care center from April 2021 to June 2021.

Results: Six cases of Covid-19 associated with Rhino-orbital-cerebral mucormycosis have been analyzed in the study. The mean age of patients was 40.67 years with a male preponderance (83.3%). The most common complaint was headache (100%), while a minority (33%) came with ocular complaints. All the patients either had a previous history of diabetes mellitus or developed increased blood sugar levels following Covid infection, and were kept on insulin to control their blood sugar levels. 4 patients (66.67%) had a history of corticosteroid use during Covid-19 hospitalization. Treatment included intravenous liposomal Amphotericin B (100%), functional endoscopic sinus surgery (66.67%), maxillectomy (33.33%) and transcutaneous retrobulbar liposomal Amphotericin B (33.33%). Amphotericin B induced nephrotoxicity, which was seen in 1 patient (16.67%). Mortality occurred in only one patient (16.67%), 25 days following successful surgery.

Conclusion: Diabetes Mellitus is the most important predisposing factor for the development of Covid-19 associated Rhino-orbital-cerebral mucormycosis. Early presentation, prompt diagnosis and timely initiation of treatment with liposomal Amphotericin B and surgical debridement along with strict blood sugar control can lead to a favorable outcome. However, regular follow-up and monitoring of serum electrolytes and kidney profile must be ensured for such patients.

Microsporidial Stromal Keratitis: Epidemiological Features, Slit-Lamp Biomicroscopic Characteristics, and Therapy

PURPOSE

Microsporidial stromal keratitis is a rare form of infectious keratitis, with only 7 cases reported in the United States to date. This study was performed to evaluate risk factors, clinical features, and response to therapy.

METHODS

A retrospective review of the medical records of all patients diagnosed with microsporidial stromal keratitis seen in the practices of the authors between 1999 and 2020 was performed. Diagnosis was determined by cytology or histopathology in corneal specimens. Risk factors, presence or absence of distinctive clinical features, and response to medical and surgical therapies were recorded.

RESULTS

Nine patients-7M:2F, aged 7 to 99 years-with microsporidial stromal keratitis were identified. Exposures to recreational water and hymenopteran insect bites, both epidemiologically linked risk factors for systemic microsporidial infection, were identified in our patients. Presence of stromal edema with features of disciform keratitis and a distinctive granular keratitis were observed in 6 of 9 and 5 of 9 patients, respectively. Poor response to medical therapy was noted. Penetrating keratoplasty was effective in curing the infection. Final visual acuity was 20/40 or better in 6 of 9 patients.

CONCLUSIONS

In patients with slowly progressive keratitis, history of exposure to recreational water or hymenopteran insects should be sought. In patients with corneal edema consistent with disciform keratitis, with evolution to a granular keratitis, microsporidia should be considered in the differential diagnosis. In cases of established microsporidial stromal keratitis, penetrating keratoplasty should be considered if prompt response to medical therapy is not noted.

Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1

Purpose

COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management.

Methods

This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021.

Results

Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05).

Conclusion

: Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.

Chronic endogenous fungal endophthalmitis: diagnostic and treatment challenges: A case report

RATIONALE

Endogenous fungal endophthalmitis (EFE) is a sight-threatening complication of systemic fungemia. As the prevalence rises, treatment remains a challenge especially when there is a failure in first-line treatment or drug-resistant fungus. This case report studies a case of chronic EFE, focusing on the diagnostic procedures, treatment options, monitoring parameters and the treatment outcome.

PATIENT CONCERNS

A 64-year-old man with underlying well controlled diabetes mellitus was treated with 2 weeks' course of intravenous antifungal fluconazole for pyelonephritis as his blood culture grew Candida albicans. Concurrently, he complained of 3 months of bilateral painless progressive blurring of vision. At presentation, his visual acuity (VA) was light perception both eyes. Ocular examination revealed non granulomatous inflammation with dense vitritis of both eyes.

DIAGNOSIS

He was diagnosed with EFE but the condition responded poorly with the medications.

INTERVENTIONS

He was treated with intravitreal (IVT) amphotericin B and fluconazole was continued. Vitrectomy was performed and intraoperative findings included bilateral fungal balls in the vitreous and retina with foveal traction in the left eye. Postoperatively, vision acuity was 6/24, N8 right eye and 2/60, N unable for left eye with extensive left macular scar and hole. Vitreous cultures were negative. He received multiple IVT amphotericin B and was started on topical steroid eye drops for persistent panuveitis with systemic fluconazole. Ocular improvement was seen after switching to IVT and topical voriconazole. Despite this, his ocular condition deteriorated and he developed neovascular glaucoma requiring 3 topical antiglaucoma agents. Panretinal photocoagulation was subsequently performed.

OUTCOMES

At 3 months' follow-up, his vision acuity remained at 6/24 for right eye and 2/60 for the left eye. There was no recurrence of inflammation or infection in both eyes.

LESSONS

Voriconazole could serve as a promising broad spectrum tri-azole agent in cases of failure in first-line treatment or drug-resistant fungus.

Tintelnotia destructans Keratitis: A Clinicopathological Report and Review of the Literature

PURPOSE

To present the first clinicopathological report of Tintelnotia destructans keratitis, a filamentous fungus and as of yet uncommon virulent ocular pathogen.

METHODS

A 70-year-old man presented with an infectious keratitis featuring a stromal infiltrate with feathery borders and a viscous hypopyon. Despite initial improvement under a combined therapy with natamycin and voriconazole, a perforation in the further course required a penetrating keratoplasty. Cultures and the corneal lenticule were available for microscopic examination and antifungal susceptibility testing. The limited literature on the subject was reviewed.

RESULTS

Microscopic examination of cultures revealed hyphae and conidia being produced in globose fruiting bodies, a common characteristic of Tintelnotia sp. Histopathology showed short-branched hyphae that grew across the cornea regardless of the orientation of the collagen lamellae. Molecular methods identified the species T. destructans. The pattern of antifungal susceptibility included amphotericin B, ciclopirox, natamycin, posaconazole, voriconazole, and terbinafine. The postoperative clinical course was without complications.

CONCLUSIONS

Although the clinical signs corresponded to the classic features of fungal keratitis, microscopic analysis revealed morphological characteristics of a fungal class that has shown little ophthalmological appearance so far. Data on T. destructans keratitis are highly limited in the literature, but all identified species shared sensitivity to terbinafine.

Unusual presentation of mucormycosis mimicking a localised sino-orbital pathology

Mucormycosis is an aggressive and deadly fungal infection, which is invariably associated with an immunocompromised patient. Mucormycosis in the head and neck region presents as skeletal necrosis, with or without soft tissue involvement. Early identification and treatment with combination of surgical debridement and parenteral antifungal therapy is critical for a favourable outcome. This paper reports an unusual presentation of mucormycosis, mimicking a localised sino-orbital pathology involving the infraorbital subcutaneous tissue and the maxillary sinus, in a 35 years old immunocompetent man. Despite aggressive antifungal therapy and surgical management, the course of disease was fatal, reiterating the high mortality associated with mucormycosis.

[A clinical analysis of 1 414 cases of fungal keratitis]

Objective: To discuss clinical features and treatments of fungal keratitis, and to provide statistical data for clinical therapy and increase the therapeutic effects. Methods: This is a retrospective case series study. An analysis was performed by collecting patients' demography features, risk factors, onset time, lab results, clinical features and treatment from 1 414 cases of fungal keratitis from January 2006 to October 2016 in Qingdao Eye Hospital, Shandong Eye Institute. Results: In the 1 414 cases (1 414 patients), 1 174 patients (83.0%) came from different areas in Shandong Province, and the rest mainly from provinces on the north of Yangtze River. The age was 40 to 60 years in 874 cases (61.4%). The onset time was often in autumn and winter. The average duration between the onset and treatment was 1 to 74 days; 942 patients (67.1%) visited our hospital in 8-30 days after the appearance of the symptoms. Corneal trauma was the most common risk factor, especially injury by plants (367 cases, 26.4%). The positive rate of direct microscopic examination of potassium hydroxide wet mounts was 96.4%. The positive rate of confocal microscopy was 89.8%. Fungi were detected in corneal ulcer scrapings and (or) diseased corneal tissues obtained during surgery from 973 patients (68.8%). Most of the fungi were Fusarium (595 cases, 61.1%), followed by Alternaria (184 cases, 18.9%) and Aspergillus (119 cases, 12.2%). There were 603 cases (42.7%) of superficial and middle stromal infiltration, 614 cases (43.4%) of deep stromal infiltration and 197 cases (13.9%) of full-thickness corneal infiltration. Diameters of the corneal ulcer lesion were mostly between 4 and 6 mm (725 cases, 51.6%), followed by<3 mm (372 cases, 26.4%) and>6 mm (302 cases, 22.0%). Hypopyon was combined in 498 cases (35.2%), corneal perforation in 34 cases (2.4%), and endophthalmitis in 58 cases (4.1%). Surgery was performed in 1 198 cases (84.8%), including penetrating keratoplasty in 416 cases (29.4%), lamellar keratoplasty in 199 cases (14.1%), and corneal ulcer debridement in 532 cases (37.6%), with an effective rate of 98.1% (408 cases), 97.0% (193 cases) and 92.8% (494 cases), respectively. Two hundred and fifteen cases (15.2%) were treated with medical therapy alone, of which 147 cases (68.4%) were cured. Fifty-six patients (3.9%) finally lost their eye balls, including 54 cases of evisceration and 2 cases of ophthalmectomy. Conclusions: Fusarium is the main causative agent of fungal keratitis in Shandong Province. Direct microscopic examination of potassium hydroxide wet mounts is a simple, rapid and effective test method. Early diagnosis can be made if the result of corneal ulcer scraping examination is positive. Antifungal drug treatments can be done in early onset time. If the drug efficacy is poor or the patient's condition gets worse, immediate surgery is the key to controlling fungal keratitis. (Chin J Ophthalmol, 2020, 56:286-293).

CLINICAL PRESENTATIONS, DIAGNOSIS, AND MANAGEMENT OUTCOMES OF CURVULARIA ENDOPHTHALMITIS AND A REVIEW OF LITERATURE

PURPOSE

To describe the clinical presentation and management of Curvularia endophthalmitis and compare with previous published literature.

METHODS

Retrospective interventional comparative case series and literature review. Eight cases with culture-proven Curvularia endophthalmitis from January 2000 to March 2018 underwent vitrectomy/vitreous biopsy, intravitreal antibiotic with or without additional procedures as appropriate. The undiluted vitreous biopsy was subjected to microbiologic evaluation. Pre-existing literature was reviewed, and the current outcomes were compared with them. The mean age at presentation, etiology, number of interventions, interval between inciting event and presentation, type of intravitreal antifungal used, anatomical, and the functional outcomes were reported and compared with pre-existing literature. A favorable anatomical outcome was defined as preservation of the globe, absence of hypotony, attached retina, and absence of active inflammation at the last visit.

RESULTS

In the current series, there were 4 men and 4 women. Mean age at presentation was 34.5 ± 13.51 years (median 30 years). Inciting event was open-globe injury in five cases and cataract surgery, trabeculectomy, and endogenous cause in one case each. Presenting visual acuity was ≥20/400 in 3 cases at presentation and 5 cases at the last visit. One case with staphyloma and endophthalmitis underwent evisceration for a painful blind eye. The patients in the current series were much younger than those described previously.

CONCLUSION

Presentation and diagnosis of Curvularia can be delayed especially in postoperative cases. Early and appropriate management with multiple interventions can result in an acceptable visual and anatomical outcome.

A case report of infectious scleritis with corneal ulcer caused by Scedosporium aurantiacum

RATIONALE

Scedosporium species is rare pathogen of ocular infection. The accurate diagnosis is delaying in many cases and the clinical prognosis is poor due to its resistance to antifungal agents. This report describes a patient with infectious scleritis and corneal ulcer caused by Scedosporium auranticum infection who required enucleation to control the infection.

PATIENT CONCERNS

A 70-year-old woman visited our clinic after experiencing ocular discomfort in her right eye for 4 days after minor ocular trauma, with soil exposure.

DIAGNOSES

Scedosporium species was isolated from a culture of corneal tissue, Scedosporium aurantiacum was identified in a culture of necrotic tissue.

INTERVENTIONS

She was started on treatment with antifungal agents, including topical amphotericin B and systemic fluconazole, but her ocular condition did not improve. Although the lesion showed temporary improvement, ocular pain and corneal ulcer recurred 3 months later. Evisceration was performed due to corneal perforation, and enucleation was also performed for dehiscence of the conjunctiva and scleral necrosis.

OUTCOMES

After enucleation, postoperative systemic voriconazole treatment controlled the infection without recurrence.

LESSONS

S aurantiacum keratitis is difficult to eradicate, even with several months of treatment with systemic and topical antifungal agents, and tends to progress to scleritis. The infection can be terminated by the orbital enucleation. Infection with this rare organism should be included in the differential diagnosis of patients with severe infectious keratitis.

Therapeutic Penetrating Keratoplasty Button Cultures in The Mycotic Ulcer Treatment Trial II: A Randomized Trial Comparing Oral Voriconazole Versus Placebo

OBJECTIVE

To compare oral voriconazole vs placebo in addition to topical antifungals in the treatment of filamentous fungal keratitis.

DESIGN

Non-prespecified, secondary case-control analysis from a multicenter, double-masked, randomized placebo-controlled clinical trial.

METHODS

Study Participants: Patients with smear-positive filamentous fungal ulcers and visual acuity of 20/400 or worse who eventuated to therapeutic penetrating keratoplasty (TPK).

INTERVENTION

Study participants were randomized to oral voriconazole vs oral placebo; all received topical antifungal drops.

MAIN OUTCOME MEASURES

TPK button culture positivity.

RESULTS

A total of 95 of 194 (49.5%) study participants enrolled at Madurai, Coimbatore, or Pondicherry, India eventuated to TPK in an average of 20.9 days (standard deviation 15.2 days, range 2-71 days). TPK button cultures were available for 67 of 95 (71%) of the TPKs performed and were positive for filamentous fungus in 45 of 67 (67%) cases. For each 1-day increase in the time to TPK there was 0.94-fold decreased odds of fungal culture positivity (95% confidence interval [CI] 0.90-0.98, P = .005). Those randomized to oral voriconazole had 1.26-fold increased odds of TPK button culture positivity after controlling for time to TPK and baseline organism, but this was not statistically significant (95% CI 0.32-4.87; P = .74). Those who underwent TPK for lack of response to medical therapy were 10.64-fold more likely to be culture positive than if the indication for surgery was perforation and this was statistically significant (95% CI 2.16-51.70; P = .003).

CONCLUSIONS

There appears to be no benefit to adding oral voriconazole to topical antifungal agents in the treatment of severe filamentous fungal ulcers. Infection rather than inflammation appears to be the reason for the worsening clinical picture in many of these patients.

[Fungal keratitis]

Fungal keratitis, or keratomycoses, are corneal infections which must be considered in cases of corneal trauma, prior corneal surgery, chronic ocular surface disease, topical corticosteroids or contact lens wear. Filamentous fungi or yeasts may be involved. Presenting clinical features such as corneal infiltrates with feathery edges and/or raised surface, intact epithelium with deep stromal involvement, satellite lesions, endothelial plaques, lack of improvement with antibiotics and worsening with steroids are suggestive of fungal keratitis. Corneal scraping for laboratory examination is mandatory. Medical management with antifungal eye drops and systemic agents should be started as soon as possible. Surgical interventions are required in a significant number of cases to control the infection. The prognosis of fungal keratitis is worse than that of bacterial keratitis.

Management of Presumed Endogenous Fungal Endophthalmitis in a Child With Acute Lymphoblastic Leukemia

The authors describe a case of presumed endogenous fungal endophthalmitis in an immunocompetent pediatric patient with acute lymphoblastic leukemia. A 15-year-old boy with a history of high-risk B-cell acute lymphoblastic leukemia status post-chemotherapy presented with acute changes in vision in his left eye. Fundus examination revealed a white bi-lobed chorioretinal lesion with overlying vitritis and associated subretinal fluid. Magnetic resonance imaging of the brain revealed small ring-enhancing lesions in the right parietal and left occipital lobes. Blood, cerebrospinal fluid, aqueous, and vitreous cultures were all negative. Bone marrow and vitreous cytology were negative for malignant cells. The patient was treated for presumed fungal endophthalmitis with systemic and intravitreal voriconazole, followed by pars plana vitrectomy with intravitreal voriconazole and amphotericin B injections. The chorioretinal lesion resolved and visual acuity recovered to 20/20. Chorioretinal infiltrates in a patient with leukemia may require treatment even in the absence of a definitive diagnostic test result. Intervention should be guided by risk analysis and clinical judgment. [J Pediatr Ophthalmol Strabismus. 2017;54:e42-e46.].

Chronic orbital and calvarial fungal infection with Apophysomyces variabilis in an immunocompetent patient

Apophysomyces is a rare fungal organism causing rhino-orbito-cerebral mycotic infections with high morbidity and mortality, typically in immunocompetent individuals. Several cases of Apophysomyces elegans orbital disease have been reported. Herein, we report a case of Apophysomyces variabilis infection involving the orbit, sinuses, and calvarium in an immunocompetent 74-year-old woman, with a review of the literature. Unlike prior cases of A. elegans classic rhino-orbito-cerebral infection, our case included diffuse calvarial lytic lesions and overlying soft tissue nodules, but without parenchymal intracranial involvement. There was radiographic and clinical evidence of infarction of the orbital contents and cavernous sinus thrombosis. Anastomoses between the superior orbital (ophthalmic) vein and diploic veins of the calvarium are believed to be primarily responsible for the unusual mode of spread on the extradural surface of the brain. Although the patient stabilized without definitive surgical intervention, her disease slowly and intermittently progressed for over a year after presentation, requiring multiple courses of antifungal treatment.

Management of rhino-orbital mucormycosis

Mucormycosis is an uncommon acute invasive fungal infection that affects immunocompromised patients. It progresses rapidly and has poor prognosis if diagnosed late. Early detection, control of the underlying condition with aggressive surgical debridement, administration of systemic and local antifungal therapies, hyperbaric oxygen as adjunctive treatment improves prognosis and survivability.

[Endogenous Candida lens abscess in a premature infant]

BACKGROUND

This case report describes an extremely rare Candida lens abscess in a premature infant (gestational age 24 weeks at birth).

CASE REPORT

After birth the infant suffered from Candida sepsis which was successfully treated with an antifungal medication. The patient was referred at the age of 6 months because of greyish alterations in the pupils but an absence of other symptoms. The examination with the patient under general anesthesia revealed a grey pupillary membrane and behind it a whitish swollen lens. A lensectomy was performed. The vitreous body was inconspicuous. Candida albicans was identified microbiologically.

CONCLUSIONS

In preterm infants dissemination of pathogens into the lens through the vascular coat of the lens is possible, which after regression of the coat is no longer accessible to systemic treatment and may thus be manifested as delayed abscess formation.

[The status quo and expectation of corneal research in China]

In China, corneal disease is currently the second leading cause of blindness. Severe donor shortage, insufficient technique supports and promotion, and the lack of corneal disease specialists due to poor systematic training are all urgent problems to be resolved. The last 5 years have witnessed a considerable progress in basic and clinical researches of corneal disease. Investigations on the pathogenesis and treatment of fungal keratitis have won an international reputation. Results from the study of corneal reconstruction with tissue-engineered and acellular matrix corneas have been tested in clinical trials with good preliminary performance. Moreover, the clinical researches of corneal refractive surgery have kept pace with the latest international progresses. However, Descemet's membrane endothelial keratoplasty needs further promotion, and the development and application of keratoprosthesis remains a blank. Although keratoprosthesis and corneal collagen cross-linking have been widely applied in Europe with satisfactory clinical efficacy, they are still under assessment by China Food and Drug Administration for approval of use.

[Iris tumor of unknown origin]

A 51-year-old woman presented with a non-specific tumor of the iris and intraocular inflammation of the left eye. The patient had a history of surgery for metastatic bowel cancer and was on chemotherapy. The lesion was excised and was found to contain fungal spores and hyphae. Microbiological testing identified growth of Candida albicans and the patient was treated with local and systemic voriconazole. After combined vitrectomy with cataract surgery, the patient's condition improved.

Allergic fungal sinusitis causing nasolacrimal duct obstruction

INTRODUCTION

Allergic fungal sinusitis is thought to represent a chronic autoimmune reaction directed against fungal elements within the sinuses, and is commonly seen in individuals with a history of chronic sinusitis that is refractory to medical therapy. The authors present a case of allergic fungal sinusitis involving the lacrimal drainage system.

CASE

A 54-year-old woman initially presented with recurrent erythema and induration of the left nasolacrimal sac due to dacryocystitis, which was unresponsive to treatment with topical and systemic antibiotics. Radiological evaluation demonstrated the presence of multiple soft tissue masses along the medial canthi. During subsequent endoscopic dacryocystorhinostomy, significant amounts of allergic mucin were found within the sinuses and marked eosinophilia was present within tissue obtained from the lacrimal sac, findings highly suggestive of allergic fungal sinusitis.

CONCLUSION

A diagnosis of allergic fungal sinusitis should be considered in patients presenting with epiphora in the appropriate clinical context. However, involvement of the lacrimal drainage system is an exceedingly unusual presentation.

[Several problems of diagnosis and treatment in fungal keratitis in China]

Fungal keratitis is one of major blindness disease in corneal infection. At present, mistake and missed diagnosis were often happened in Fungal keratitis. Initial doctor was insufficient knowledge of diagnosis. There were not to do etiology examination in corneal fungal infection, and lead to some case getting worse during medicinal treated. Highly ratio patients need controlled infection by corneal transplantation due to severe lack antifungal eye drops, and poor understood the way of antifungal medicine in clinic. Finally, Fungal keratitis is still one of major intractable disease in corneal infection, because some doctor were short of experience to hold surgical opportunity and indication, and corneal donor severe shortage in China.

Treatment of microsporidial keratoconjunctivitis with repeated corneal swabbing

PURPOSE

To report the effect of repeated corneal swabbing in patients with microsporidial keratoconjunctivitis.

DESIGN

Retrospective noncomparative case series.

METHODS

Sixteen eyes of 14 healthy patients with microsporidial keratoconjunctivitis were diagnosed based on the detection of microsporidia in corneal scrapings using Gram stain, the modified Kinyoun acid-fast stain, or both. Polymerase chain reaction plus gene analysis of the microsporidian 16S ribosomal RNA had been performed in 10 patients who sought treatment between 2010 and 2011. Some of the lesions were scraped for procurement of specimens. The remaining lesions were wiped off gently by cotton swabs. Repeated swabbing was performed if infection persisted or new lesions were observed at follow-up. To prevent secondary bacterial infection, 0.3% norfloxacin or 0.25 % chloramphenicol were prescribed.

RESULTS

The mean age was 52.2 years. All patients had the characteristic disseminated, punctate, slightly elevated, white epithelial lesions. The denser white lesions could be removed easily after gentle swabbing, and most epithelium remained intact. The 10 cases with positive polymerase chain reaction results were all identified to be Vittaforma corneae. The mean number of corneal swabbing was 3.3, and the mean disease resolution time was 6.6 days. No patients had recurrence or loss of visual acuity at last follow-up.

CONCLUSIONS

Repeated swabbing effectively can eradicate corneal epithelial microsporidial lesions in approximately 1 week. It is easy to perform, less painful, and more acceptable for the patients.

[Severe contact lens-associated fungal keratitis]

A 23-year-old man presented with severe contact lens-associated keratitis and descemetocele with pre-existing drug therapy. After 1 week of intensive antibiotic treatment Aspergillus fumigatus was identified. Despite adjusted antimycotic treatment a corneal perforation occurred. Due to peripheral scleral infiltration the cornea was primarily closed with a double layer amniotic membrane in order to avoid a sclerokeratoplasty with a bad prognosis. After 2 weeks the peripheral corneal situation stabilized and a simple keratoplasty á chaud could be performed. After surgery and adjusted drug therapy, no adequate signs of recovery occured. In repeated microbiological testing an additional Candida albicans infection was diagnosed and therapy was readjusted. This resulted in a cure of the corneal infection. After 5 years and a re-keratoplasty the patient presented with a clear corneal transplant and a corrected visual acuity of 20/25.

[Endophthalmitis in course of candidosis--a case report]

PURPOSE

Description of a rare case of bilateral fungal endophthalmitis in a patient and the associated diagnostic and therapeutic difficulties.

MATERIAL AND METHODS

Patient 28 years old was diagnosed because of bilateral deterioration in endophthalmitis. Therefore, the diagnostic possibilities were run down and material taken from the vitreous chamber were handed to determine the Candida spp. antigen using Elisa test, standardized for serum and cerebrospinal fluid. Combination therapy including drugs and surgery were performed.

RESULTS

Ophthalmoscopy OP/OL showed the presence of "clusters of cotton" in vitreous body characteristic for ocular candidosis. Targeted treatment for Candida spp. with voriconazole were based on a very high concentration of mannan antigen in the resulting of the test. The final diagnosis was established after microbiological examination of material taken during vitrectomy.

CONCLUSIONS

High level of mannan antigen Candida spp 4259.83 in vitreous body may indicate a fungal endophthalmitis. fungal endophthalmitis, ocular candidosis, endogenic infection of the eye.

[Update of fungal keratitis diagnosis and treatment]

The fungal keratitis is a common ocular disease, and its etiological factor and pathogenesis are definite, but the treatment is difficult and prognosis is poor. It is vital for fungal keratitis to be diagnosed rapidly and treated effectively. This paper had summarized the germ spectrum changes of fungal keratitis, new means of diagnosis adopted both in laboratory and clinical practices, such as improved staining method, confocal biomicroscope, technique of PCR and molecular sequence. There were some details of various new anti-fungal drugs and the available alternatives of surgical treatment for best treating effects.

[Fusarium keratitis]

The case of a previously healthy 48-year-old patient (not a contact lens wearer) with a Fusarium keratitis is reported. He had developed a deep corneal ulcer with total stromal infiltration (Fusarium ssp.). An intensive topical and systemic antiinfectious medication was initiated, along with some procedures (keratoplasty, rinsing of the anterior chamber). However, the infection progressed (endophthalmitis), and an enucleation was necessary. Despite modern drug therapy and surgical intervention, fungal keratitis can cause an enucleation.

Corneal ulcer due toNeocosmospora vasinfectain an immunocompetent patient

We report a case of Neocosmospora vasinfecta keratitis in a 55-year-old man. While the patient did not recall any specific trauma or eye injury, he might have sustained a trivial wound during the course of his duties as a farmer. Direct examination of corneal scrapings revealed fungus filaments. As topical treatment with natamycin and econazole and subsequent systemic ketoconazole therapy failed, a full thickness therapeutic keratoplasty was performed. Post-operative treatment with amphotericin B and clotrimazole combined with cyclosporine resulted in a complete cure. The residual corneal infiltration in the recipient cornea became clear in a week. The fungal isolate was initially identified as a Fusarium species, but later reidentified through the use of morphological characteristics and sequence analysis of the internal transcribed spacer region as N. vasinfecta. The latters is a Hypocrealean fungus not hitherto reported as a causative agent of keratomycosis.

Periocular infection

PURPOSE OF REVIEW

The aim of this article is to acquaint the clinician with advances in the diagnosis and management of periocular cellulitis and to alert physicians to emerging pathogens.

RECENT FINDINGS

The most important, recent infectious disease entity to consider is community-acquired methicillin-resistant Staphylococcus aureus, which is emerging as a significant problem across the country. The potential devastation caused by necrotizing fasciitis is also reviewed, since this diagnosis is easily missed early in its course. A variety of less common and frankly atypical pathogens is presented to remind the clinician that, on occasion, the hoofbeats are indeed a zebra's.

SUMMARY

Periocular cellulitis remains an important and common entity in ophthalmology. The emergence of new pathogens and the resistance to conventional treatment by others are a cause for concern and require an understanding of management strategies.

Post-LASIK Epithelial Dendritic Defect Associated With Alternaria

PURPOSE

To report a case of a dendritic epithelial defect with interface inflammation associated with Alternaria sp. after laser in situ keratomileusis (LASIK) surgery.

METHODS

A case report of a 46-year-old woman who presented with a dendritic epithelial defect and interface inflammation after LASIK surgery.

RESULTS

After an apparent post-LASIK herpes simplex keratitis with related interface inflammation failed to respond to medical therapy, cornea culture results were positive for Alternaria fungal sp. 2 weeks and 6 days after presentation. Viral cultures and polymerase chain reaction were negative for herpes simplex virus. Six months after penetrating keratoplasty (and 1 year after LASIK), the patient underwent a cataract extraction OD. Best-corrected visual acuity 18 months after the original LASIK procedure was 20/25 OD.

CONCLUSIONS

Alternaria keratitis may present with a dendritic epithelial defect with interface inflammation mimicking herpes simplex virus.

Rhinocerebral mucormycosis with perineural spread

We describe the histopathologic findings of perineural invasion in orbital mucormycosis in a man with diabetes in ketoacidosis. Linear enhancement on MRI beginning at the orbital apex was correlated with fungal tracking of the trigeminal and lacrimal nerves. Mucormycosis can spread considerable distances from its primary focus of infection along peripheral nerves, a phenomenon that can be identified clinically with contrast-enhanced MRI.

Metastatic endophthalmitis

Endophthalmitis carries a poor visual prognosis for patients and can be a potentially blinding condition that may result in loss of the eye. Early diagnosis and prompt treatment are imperative to save the eye. Delay in diagnosis affects visual prognosis and therefore doctors should be aware of the presenting features of endophthalmitis. Urgent ophthalmic referral is advised as soon as a diagnosis is suspected.

Traumatic lenticular abscess: clinical description and outcome

PURPOSE

To analyze cases with posttraumatic lenticular abscess and study the etiology, clinical presentation, management, and outcome.

DESIGN

Retrospective case series.

METHODS

Seventeen eyes of 17 patients with traumatic lenticular abscesses were managed with extracapsular cataract extraction after aspirating the abscess.

RESULTS

The mean age of the patients was 40.3 years, and males constituted 82%. The mean time to presentation after injury was 14.35 days (range, one to 60 days), and the patients had a mean follow-up of 125.94 days (range, 21 to 300 days). Culture of the lenticular abscess revealed bacterial growth in eight cases (47%) and fungi in four cases (23.5%). In five (29.4%) cases, culture was negative. Staphylococcus epidermidis grew in seven cases (41%). Thirteen eyes (77%) had best-corrected visual acuity better than 20/120.

CONCLUSIONS

Surgical removal of the abscess, with systemic and local antimicrobial treatment is effective in cases of posttraumatic intralenticular abscess.

Posttraumatic Aspergillus terreus endophthalmitis masquerading as dispersed lens fragments

A 20-year-old man developed increasing inflammation with a hypopyon 3 weeks after primary repair of a corneal laceration. An occult anterior capsule puncture was suspected as the stimulus for the inflammation. When aspiration of the suspected hydrated lens material was not curative, a vitrectomy with injection of intravitreal antibiotic agents including amphotericin (0.0125 mg) was done the following day; the culture failed to grow fungal organisms. A repeat vitrectomy was performed 1 week later, and the culture grew Aspergillus terreus. This was determined to be resistant to amphotericin so voriconazole was injected intravitreally. The inflammation recurred, and the eye required enucleation because of blindness and intractable pain. Fungal endophthalmitis should be considered in cases of delayed-onset inflammation after trauma and may be due to organisms resistant to amphotericin.

Fungal keratitis in Melbourne

BACKGROUND

Description of the clinical and microbiological spectrum of fungal keratitis at a tertiary eye care hospital in Melbourne, Australia.

METHODS

Retrospective review of all patients with keratitis with positive fungal cultures from corneal or associated samples presenting to the Royal Victorian Eye and Ear Hospital, Melbourne, Australia from July 1996 to May 2004. Demographic data, predisposing factors, features on presentation, management, outcomes and microbiological data were collected and analysed.

RESULTS

The study included 56 eyes of 56 patients. Thirty-five patients were treated as 'typical' fungal keratitis and used for description and analysis, with a mean follow up of 18 months. Ocular trauma (37.1%), chronic steroid use (31.4%) and poor ocular surface (25.7%) were the major predisposing factors. Perforation was seen in 25.7% of patients, penetrating keratoplasty was required in 9 (25.7%) patients and evisceration was performed in 2 (5.7%) patients. Candida albicans (13 patients, 37.2%) was the most common fungal isolate accounting for more than one-third of all organisms followed by Aspergillus fumigatus (six patients, 17.1%) and Fusarium sp. (five patients, 14.3%).

CONCLUSIONS

The present study describes the clinical patterns of fungal keratitis in Melbourne, Australia and contrasts them with reports from other areas of the world. A high incidence of C. albicans infection and the prior use of steroids in high proportion of the patients are highlighted in this study.

Pediatric Microbial Keratitis in Taiwanese Children

OBJECTIVE

To study the clinical and microbiological characteristics of pediatric microbial keratitis in Taiwan.

METHODS

The medical records of 81 eyes with microbial keratitis in 78 children aged 16 years or younger who were diagnosed and treated at Chang Gung Memorial Hospital, Taipei, Taiwan, from July 1, 1998, through December 31, 2002, were retrospectively reviewed. Predisposing factors, microbial culture results, clinical course, and visual outcomes were analyzed.

RESULTS

Predisposing factors were contact lens wear (33 cases [40.7%]), trauma (17 cases [21.0%]), ocular disease (12 cases [14.8%]), and systemic disease (9 cases [11.1%]). Eight of the 33 contact lenses were rigid gas-permeable lenses that were worn overnight for orthokeratology. Forty-seven (58.0%) of the 81 eyes were culture positive. The most common isolates were Pseudomonas aeruginosa (21 eyes [44.7%]) and Staphylococcus aureus (9 eyes [19.1%]). Twelve (14.8%) of the 81 eyes required surgical intervention. Of the 68 eyes that had a best-corrected visual acuity available at the last follow-up, 33 eyes achieved best-corrected visual acuity of 20/25 or better.

CONCLUSIONS

Predisposing factors for pediatric infectious keratitis vary with age. In the teenage years, the most predominant risk factor is contact lens wear. Infectious keratitis resultant from overnight orthokeratology lenses should receive particular attention. Parents of children who consider overnight orthokeratology should evaluate the benefit of temporary myopia reduction and the risk of infection. Identification of predisposing factors and microorganisms may be helpful for early recognition and treatment of pediatric microbial keratitis.

Matrix metalloproteinases (MMP-8, MMP-9) and the tissue inhibitors of metalloproteinases (TIMP-1, TIMP-2) in patients with fungal keratitis

PURPOSE

To study the infiltrating cells and quantify the levels of matrix metalloproteinases (MMP-8, MMP-9) and tissue inhibitor of metalloproteinases (TIMP-1, TIMP-2) in the cornea, tear, and serum of patients with fungal keratitis.

METHODS

Experimental study. Infected corneal tissue from 4 patients with fungal keratitis (group 1) scheduled to undergo therapeutic keratoplasty accounted for the histopathologic and cytospin smear analysis. Ten patients with fungal keratitis from group 2 served for the quantification of MMPs and TIMPs. Five patients with keratoconus undergoing penetrating keratoplasty and 5 cadaver corneas were chosen as controls for group 2. Corneal buttons obtained during keratoplasty, 15 to 20 microL of tears collected using the capillary flow method, and 3 mL of blood was obtained from patients with fungal keratitis and patients with keratoconus. Corneal button sections from group 1 were stained with hematoxylin and eosin and Grocott methenamine silver nitrate for the histopathologic studies and Giemsa staining for the cytospin smear analysis. Enzyme-linked immunosorbent assay was used for the quantification of total MMP-8, MMP-9, TIMP-1, and TIMP-2 in the corneal homogenates, tear, and serum samples of group 2.

RESULTS

Corneal sections from group 1 revealed dense fungal filaments and a large proportion (91.4% +/- 38%) of polymorphonuclear leukocytes (PMNs). Significant elevation in the levels of MMP-8 and MMP-9 (P < 0.05) in the fungal keratitis corneas was observed in group 2 compared with the cadaver and keratoconus corneas. The ratio of MMP/TIMP was also higher in the fungal keratitis corneas.

CONCLUSIONS

Infiltrating PMNs in the cornea of patients with fungal keratitis contributed to the increased activities of MMP-8 and MMP-9, thereby enhancing tissue destruction and derangement.

Successful Treatment of Paecilomyces lilacinus Keratitis in a Patient With a History of Herpes Simplex Virus Keratitis

PURPOSE

To report a case of Paecilomyces lilacinus keratitis, initially misdiagnosed as Penicillium sp., in a patient with a long-standing history of herpes simplex virus (HSV) keratitis.

METHODS

A retrospective case report.

RESULTS

A 62-year-old man developed P. lilacinus keratitis. He was treated with topical steroids for immune stromal keratitis secondary to HSV before developing the fungal keratitis. Initial corneal cultures were positive for Penicillium sp., but subsequent cultures identified P. lilacinus to be the causative organism. The patient later developed an anterior chamber abscess. Three penetrating keratoplasties, as well as intravitreal injection of amphothericin B, topical miconazole, subconjunctival miconazole, and systemic fluconazole, were required to eradicate the infection.

CONCLUSION

To our knowledge, this is a first report of P. lilacinus keratitis in a patient with a previous history of HSV keratitis. The causative organism was initially reported as Penicillium sp. on 2 occasions, before the correct diagnosis was made. Paecilomyces keratitis progressed to an anterior chamber abscess in this eye. Aggressive treatment, including a therapeutic penetrating keratoplasty, intravitreal amphothericin B injection, topical miconazole, and systemic fluconazole can be successful in eradicating this extremely difficult-to-treat infection.

Rhinocerebral mucormycosis with orbital and intracranial extension: a case report and review of optimum management

Rhinocerebral mucormycosis is a devastating, rapidly progressive and often fatal opportunistic fungal infection predominantly affecting individuals with underlying metabolic and/or immunological compromise. Intracranial extension of the disease has invariably been associated with mortality.We present a review of optimum management of rhinocerebral mucormycosis and a case report of sinonasal mucormycosis with intracranial and orbital extension which was treated successfully with a combination of systemic liposomal amphotericin B therapy and wide surgical debridement.

Endogenous endophthalmitis with azole-resistant Candida albicans--Case report and review of the literature

Candida endophthalmitis accounts for the majority of fungal endophthalmitis. Despite its clinical relevance there are no controlled trials on different treatment regimens. We report a case of endogenous endophthalmitis caused by azole-resistant Candida albicans following abdominal surgery in an otherwise healthy woman, and review the literature concerning treatment recommendations. In consideration of the serious outcome with loss of sight in insufficiently treated endophthalmitis we like to increase awareness to this disease entity and the possibility of azole-resistance, even in treatment-naive patients.

Early onset endophthalmitis caused by Aspergillus species following cataract surgery

PURPOSE

To report a series of patients with early onset Aspergillus endophthalmitis following cataract surgery.

DESIGN

Retrospective consecutive case series.

METHODS

Medical records were reviewed of all cases of endophthalmitis caused by Aspergillus after cataract surgery treated at the authors' practices between 1992 and 2005.

RESULTS

Five patients were identified. Two patients were immunocompromised (one on oral corticosteroids and one on chemotherapy for lung cancer). The mean number of days between cataract surgery and diagnosis with endophthalmitis was 29 (range, 10 to 62 days). Three eyes (60%) were enucleated despite a variety of treatments. In addition to vitrectomy and injection of antifungal agents, the other two eyes underwent surgical debridement of a localized necrotic nidus. Final visual acuity was 20/30 in one eye and 20/200 in the remaining eye.

CONCLUSIONS

Aspergillus should be considered in the differential diagnosis of early onset endophthalmitis following cataract surgery. Visual outcomes are generally poor and enucleation is common in these patients.