Fungal keratitis

1. FUNGAL KERATITIS
Aseel AL Rashdi
Ophthalmology Resident 1st year

2. Pathophysiology
◦ Serious ocular infection with potentially catastrophic visual results.
◦ Starts when the epithelial integrity is broken either due to trauma or
ocular surface disease and the organism gains access into the tissue
and proliferates.
◦ Proteolitic enzymes, fungal antigens and toxins Tissue necrosis

3. Etiology ?
◦ Non-filamentous (yeast) :
◦ Candida
◦ filamentous with septae :
◦ Aspergillus spp
◦ Fusarium spp
◦ Cladosporium spp
◦ Curvularia
◦ Filamentous non-septated : eg .Rhizopus.

4. Risk factors ?
◦ Topical Steroid Use
◦ Immunosuppression
◦ Diabetes
◦ Agricultural Trauma
◦ Contact Lens Wear
◦ Chronic Keratitis
◦ Eye Surgery (LAISK ,PK , PKP)

5. Red Flags for diagnosis
◦ Corneal Ulcers Unresponsive To Broad-spectrum Antibiotics
◦ Satellite Lesions
◦ Scanty Secretions In a large ulcer

6. History
◦ Pain
◦ Foreign Body Sensation
◦ Redness, Tearing
◦ Blurred Vision
◦ Photophobia
◦ H/O Trauma
◦ H/O Ocular Surface Disease.
◦ Immune Compromised Patient

7. Physical examination
◦ Conjunctival injection
◦ Epithelial defect
◦ Suppuration
◦ Stromal infiltration
◦ Anterior chamber reaction
Non Specific

8. More specific for Fungal keratitis
◦ Ulcer looks dry ,
Elevated Edges,
Rough Texture, gray-
white color
◦ Typical irregular
feathery-edged
infiltrate
◦ Hypopyon

10. ◦ Satellite Lesions
◦ Endothelial Plaque
◦ Immune ring of Wessely

11. Filamentous fungi
(i.e. Fusarium, Aspergillus, Curvularia)
Nonfilamentous fungi (i.e. Candida)
•Gray-white corneal stromal opacity with
feathery white border
•Satellite lesions surrounding 1° infiltrate
•Epithelial defect or corneal ulcer
•Anterior chamber reaction
•Hypopyon
•Inflammatory ring
•Yellow-white stromal infiltrate
•Epithelial defect or corneal ulcer
•+ /- Anterior chamber reaction
•+ / - Hypopyon

12. Investigations
Saboraud
agar
chocolate
agar
blood agar
1

14. KOH
◦ KOH is a rapid and inexpensive way to detect fungi. It has a sensitivity of
61–94 % and specificity of 91–97 % of detecting FK in different studies.
Ansari, Z., Miller, D., & Galor, A. (Current thoughts in fungal keratitis: diagnosis and treatment. Current fungal infection reports, 7(3), 209-218. 2013.

15. 3 weeks !
A negative culture does not rule out the presumed diagnosis because it is not 100 % sensitive.

16. ◦ PCR
Time saving : 4–8 hours
positive fungal cultures takes up to 35 days.
Expensive
oBiopsy or AC tap if culture negative and high suspicion
Investigations 2

17. Case
◦ 62 Y Female
◦ PMH: IDDM
◦ POH : LE blind RE : glaucoma , post PKP + PCIOL 14/9/2017 , ? PDRP
◦ Presented with : FB sensation, pain , redness in RE.
◦ No H/O trauma or CL wear.
◦ Gtts : Azarga
◦ Regular Medications : Aspirin , Simvasatatin , Sitagliptin- Metformin , Gliclazide ,
Glargine
◦ O/E : VA : OD HM OS NPL
◦ IOP : Not possible

18. ◦ RE :
◦ Conj congested , epithelial
defect 4X3 mm , Stain ++ ,
Infiltrate ++ , Endothelial and
stromal infiltrate .
◦ PKP graft in situ , no suture
abscess .
◦ AC deep and quiet.
◦ Lens : PCIOL.
◦ Vitreous : hazy.
◦ Retina : attached.
◦ LE : NPL

19. Inpatient Follow Up
◦ Impression : bacterial keratitis
◦ Started Fortified RE drops : cefuroxime , Ceftazidime 1 hrly + oral
Ciprofloxacin.
◦ Daily examination .
◦ No improvement after 3 days + worsening of symptoms and clinical
findings .
◦ Fungal keratitis was suspected.
◦ KOH came –ve .
◦ Antifungal treatment was started .
◦ Awaited culture results.

20. Treatment (Medical management )
◦ Topical antifungal agents ( mainstay of treatment )
◦ Natamycin (FDA-approved)
◦ Amphotericin B
◦ Voriconazole
◦ Econazole
◦ Clotrimazole
Recent review (2012) found no significant differences between treatment regimens and no
evidence that any particular drug or combination of drugs is more effective in the
management of fungal keratitis.”
Ansari, Z., Miller, D., & Galor, A. (Current thoughts in fungal keratitis: diagnosis and treatment. Current fungal infection reports, 7(3),
209-218. 2013.

21. Combination oral
◦ Oral fluconazole and ketoconazole are absorbed systemically with good
levels in the anterior chamber and the cornea
◦ Indications :
◦ Severe deep keratitis
◦ Scleritis
◦ Endophthalmitits

22. Adjunctive treatment
◦ Antibiotics
◦ Cycloplegic agent
◦ Systemic analgesic and anti-inflammatory- to relieve pain and decrease edema.
◦ Multivitamins to improve immunity and help in healing
◦ Systemic ascorbic acid to accelerate corneal remodeling and healing
◦ Antiglaucoma medication

23. Duration of antifungal treatment
◦ 4-6 weeks on average.
◦ If no improvement in 1 week ?
◦ Check lab results
◦ Change medications
◦ If the Infection continues to worsen?
◦ Consider Surgical interventions
*Tuli, S. S. (2011). Fungal keratitis. Clinical ophthalmology (Auckland, NZ), 5, 275.

24. Signs of improvement
◦ Decreased pain
◦ Decreased size of infiltrate.
◦ Disappeared satellite lesions
◦ Rounding of feathery margins

25. Treatment ( Surgical management )
◦ Epithelial debridement.

26. ◦ Intracameral injection voriconazole / amphotericin B (50 µg/0.1 mL)
◦ Intrastromal therapy voriconazole and amphotericin B
◦ Intravitreal amphotericin B, fluconazole and voriconazole
◦ Subconjuctival therapy miconazole (10 mg in 0.5 mL) and fluconazole (0.5–1.0 mL of a 2%
solution);
Treatment ( Surgical management )

28. Treatment ( Surgical management )
◦ Conjunctival flap
◦ Penetrating or lamellar keratoplasty (PKP)
or (LK) is the definitive management.

29. Recurrence Post PKP ?
◦ A large study of 180 cases of therapeutic penetrating keratoplasty
in Nepal showed a recurrence rate of infection in 26% of cases of
fungal keratitis while the recurrence rate was only 6% in bacterial
infections.
Bajracharya L, Gurung R. Outcome of therapeutic penetrating keratoplasty in a tertiary eye care
center in Nepal. Clin Ophthalmol. 2015;9:2299–2304.

30. References
◦ American Academy of Ophthalmology
◦ Kanski clinical ophthalmology
◦ Ansari, Z., Miller, D., & Galor, A. (Current thoughts in fungal keratitis: diagnosis and
treatment. Current fungal infection reports, 7(3), 209-218. 2013.
◦ Bajracharya L, Gurung R. Outcome of therapeutic penetrating keratoplasty in a tertiary eye care
center in Nepal. Clin Ophthalmol. 2015; 9:2299–2304.
◦ Tuli, S. S. (2011). Fungal keratitis. Clinical ophthalmology (Auckland, NZ), 5, 275.