Possibilities and problems of mycotic keratites therapy in the hospital

Fungi are most common cause of severe inflammation of the cornea, resulting in blindness and loss of vision [6]. According to various researchers, fungi are the cause of keratitis in 40-50% of all microbial keratitis cases [1, 3]. Treatment of keratomycosis in the Russian Federation is carried out by methods other than intended. Lack of skills and availability of diagnostics, official etiotropic therapy for use in ophthalmology for ophthalmologists, unequal conditions in the fight against ophthalmomycosis. This is partly due to the lowered level of «myco-alertness», which leads to long-term ineffective «healing» of antibacterial drops, the duration of the patient’s suffering and results in the loss of the eye functionally and — in some cases — anatomically [7]. Global eye removal counts revealed that this method was used in 8-11%, which represents an annual loss of 84,143-115,697 eyes [6]. Key words: keratomycosis, mycotic keratitis, treatment, therapy.

Intrastromal Injection of Voriconazole in the Treatment of Deep Fungal Keratitis - A Prospective Study in a Tertiary Care Centre in South India

BACKGROUND Treatment of fungal ulcers is one of the most challenging tasks. Various topical antifungal drugs have poor corneal stromal penetration. Voriconazole is a broad spectrum drug and is an effective agent for the treatment of fungal keratitis as a topical preparation. It is potent against a broad range of clinically significant fungal infections both in the eye as well systemically. In tropical climatic conditions filamentous fungi commonly cause eye infections and are associated with poor visual outcomes. The treatment options for mycotic ulcers are limited, therefore direct intrastromal injections are helpful in the management of these deep mycotic keratitis. We wanted to evaluate the role of intrastromal injection of voriconazole in the management of deep fungal keratitis not responding to conventional therapy. METHODS This an interventional case series study done at a tertiary care centre in south India from the year April 2019 to August 2020. Eight eyes of eight patients with microbiologically proven deep stromal recalcitrant mycotic keratitis not responding to topical antifungal medications were evaluated. Voriconazole 50 microgram / 0.1 ml was injected around the infiltrate in the corneal stroma as an adjunctive to the topical antifungal treatment. Main outcome measure was a reduction of the size of the infiltrate and ulcer and decrease in infection on regular follow ups. RESULTS Before injecting voriconazole, all the cases were of either gradually worsening of lesions on topical treatment, or not responding to topical treatment. After the injection a rapid decrease in the size of corneal ulcer, hypopyon, and infiltration was seen within 3 weeks. CONCLUSIONS Targeted delivery of intrastromal voriconazole may be a safe and effective way in the management of deep seated fungal ulcers which respond poorly to conventional treatment procedures, thus reducing the need for further surgical treatment. KEYWORDS Intrastromal Injection, Voriconazole, Fungal Keratitis, Deep Mycotic Keratitis

Profile of fungal keratitis in a Sub-Himalayan territory of north India

Aim: To study the microbiological and epidemiological profile of patients with suppurative corneal ulcer presenting in a rural referral center situated in a Sub-Himalayan territory of north India. The study was conducted to evaluate the epidemiology and frequency of mycotic keratitis among the patients of suppurative corneal ulcer and to identify various fungal species as etiological agents. Methods: Corneal scrapings from 56 patients of suppurative corneal ulcers were subjected to direct microscopy and culture. Results: Of the 56 cases of suppurative corneal ulcer investigated, fungal etiology was identified in 18 (32%) cases. Most of the patients (82.1%) worked in agriculture. Trivial trauma with vegetative matter was the most common predisposing factor. Fusarium and Acremonium species were the most common fungi isolated, followed by Aspergillus. Four cases of rare mycotic keratitis caused by Paecilomyces lilacinus, Scedosporium apiospermum, Monilia sitophila, and Ulocladium species were detected. Four cases were smear positive (10% KOH wet mount) but culture negative. Analysis of KOH wet mount was done using culture as gold standard. The sensitivity and specificity of KOH wet mount was 71.43% and 90.48%, respectively. Conclusion: Direct microscopy and culture has a greater diagnostic value in the management of suppurative corneal ulcer. The authors have observed changes in the pattern of organisms identified as cause of fungal keratitis in the region. Rare species of fungi may also be detected if corneal scrapings are collected for direct microscopy and culture from all the cases of suppurative corneal ulcers greater than 2 mm.

Pathogenesis and Clinical Features of Fungal Keratitis (Review)

In this review we presented the information about pathogenesis of mycotic keratitis and the most characteristic clinical signs that can help ophthalmologists to suspect mycotic etiology. In conditions of poor accessibility and informativeness of laboratory and instrumental diagnostic tests, the analysis of the anamnesis and the clinical signs remain the only information that can be used by a physician while making a diagnosis and choosing treating strategies. This review contains the results of a number of studies. In the review we show the progression phases of cornea mycotic infection, among them adherence, invasion, morphogenesis and toxigenicity. We also reveal that the most characteristic clinical signs of mycotic keratitis are scalloped rough edge of stromal defect, prominent dry crumby or caseous structured view of infiltrates and necrotic masses, satellite infiltrates, certain changes of color of the defected area. Heaviness of mycotic keratitis ulcer defect has a correlation with an unfavourable prognosis for disease. Mycotic keratitis during contagion can be complicated by mycotic glaucoma with a malignant disease course and endophthalmitis. There can be cases with mixed infection. While Almost No clinical sign is pathognomonic for keratomycoses, summing up all the signs can verify the diagnosis. Ophthalmologists need training in the recognition the clinical signs of infectious keratitis. Also new methods of fast diagnostics of infectious keratitis etiology and implementation on a large scale are needed.

FONSECAEA PEDROSOI – A CAUSE OF OCCULAR CHROMOBLASTOMYCOSIS

Fonsecaea pedrosoi (F. pedrosoi) is dematiaceous fungus and is the most common cause for chromoblastomycosis. It affects the exposed skin, mostly of the lower extremities. Arare case of mycotic keratitis was diagnosed in our hospital caused by F. pedrosoi. Corneal sample received in the laboratory was processed by standard mycological methods, F. pedrosoi was isolated, patient was started on antifungals his condition improved and there was no relapse. This case report shows that F. pedrosoi can infect cornea. Further, a prompt diagnosis and vigorous treatment improves patient's clinical condition.

PROFILE OF KERATOMYCOSIS IN A TERTIARY CARE TEACHING HOSPITAL IN WESTERN UTTAR PRADESH, INDIA

Introduction- Fungal keratitis or keratomycosis refers to an infective process of the cornea caused by fungi capable of invading the ocular surface. Aims & Objectives-i) To determine the frequency of fungal keratitis in clinically diagnosed cases ii)To identify the aetiological agents of keratomycosis. iii) To assess the precipitating factors associated with it. Method- A retrospective data of 2 years was analyzed to study the number of cases of fungal keratitis, from among the corneal scrapings submitted to the Department of Microbiology, examined for the presence of fungal elements by direct microscopic methods and for the fungal growth in culture. Results-The frequency of fungal keratitis in clinically diagnosed cases was 28.6 %. Among the positive cases, males outnumbered females with the ratio of 1.67:1. The maximum number of positive cases were seen in the age group of 21-30 years, followed by the age groups of 31-40 years and 11-20 years. The most common cause of fungal keratitis was Aspergillus flavus (31.25 %), followed by Aspergillus fumigatus (18.75 %), Fusarium solani and Candida albicans (12.5 % each ), and Cladophialophora bantiana, Curvularia, Mucor and Candida tropicalis (6.25 % each ). Aspergillus species were found to be isolated from 50% of cases of keratomycosis. Filamentous fungi were predominantly associated with mycotic keratitis, accounting for 81.25% of cases, as compared to yeasts which had caused keratitis in 18.75% of cases. Amongst the cases of keratomycosis, all were positive for fungal growth on culture, out of which 81.25% cases were also positive for the presence of fungal elements on direct microscopy. Discussion: Keratomycosis is the leading cause of ocular morbidity worldwide, including India. Fungal agents causing keratitis should receive special attention due to their opportunistic behaviour and indolent course of disease. Lack of early diagnosis and treatment prelude the onset of complications, which may compromise the patient’s vision and thereby the quality of life. Conclusion: Regular surveillance and scrutiny of mycotic keratitis is important and essential to understand the pattern of fungi, existing or emerging, so as to prevent the unnecessary and irrational usage of antibiotics.