Successful Management of Culture-Negative Fungal Keratitis with Epithelial Keratectomy and Intracameral Fluconazole Injection: A Case Report

A 69-year-old female patient presented with a therapy-resistant corneal ulcer due to contact lenses, which had been present in the left eye for 1 month. The best corrected visual acuity at the first visit was 0.2. Keratitis with a central corneal ulcer was found. A corneal curettage was performed followed by inpatient therapy with antibiotic eye drops. The first PCR result was negative and the microbiological culture was sterile after 48h. The clinical findings improved during the hospital stay. There was a decrease in the size of the corneal ulcer and an increase of best corrected visual acuity up to 0.4 so that the patient was discharged. After 8 weeks the patient presented again with a painful eye and visual decline to 0.1. The left eye showed a fulminant keratitis with corneal abscess so that a second course of therapy was initiated. The PCR of the second corneal curettage was positive for Fusarium. Antifungal therapy with natamycin 5 % eye drops (via the international pharmacy) and systemic antifungal therapy with voriconazole (2 × 200mg) were initiated. Due to personal circumstances the patient rejected corneal transplantation, therefore, local and systemic antifungal outpatient treatment was continued for another 2 months until keratoplasty à chaud of the left eye could be performed. At this time there was a clear reduction of inflammation but a descemetocele developed. The patient was treated with local and systemic antifungal therapy (under control of liver and kindney parameters in blood) for 3 months postoperatively in addition to administration of local and systemic steroids. In cases of therapy-resistant keratitis, a Fusarium keratitis should always be considered. Corneal curettage ahead of therapy is very important. Natamycin 5 % eye drops are the first choice of topical antifungal medication in cases of Fusarium keratitis. Even though intensive local and systemic therapy are performed, patients often require corneal transplantation. Due to a high rate of recurrence a longer local and systemic antifungal therapy is required. In the case described here, there was a clear corneal graft without Fusarium recurrence 1 year after surgery and it is presumed the prolonged antifungal therapy before and after surgery was an important factor for this clinical outcome.

Delayed-onset fungal keratitis after endophthalmitis

Aureobasidium pullulans is a rare cause of fungal keratitis. A 73-year-old man underwent Automated Lamellar Therapeutic Keratoplasty (ALTK) for healed trachomatous keratopathy in his left eye. Five days later, he developed a graft infection. Cultures from corneal scraping showed findings consistent with Aureobasidium pullulans. The keratitis failed to respond to intensive topical and systemic anti-fungal therapy. Hence, the lamellar graft was removed. Despite this, the clinical condition deteriorated and a therapeutic penetrating keratoplasty had to be carried out to salvage the eye. At 1 year follow-up, there was no recurrence of infection. Graft infection with Aureobasidium pullulans may not be amenable to topical and systemic antifungal therapy and a penetrating keratoplasty may be required for control of infection.

Fungal hyphae growing into anterior chamber from cornea

Objective: Corneal grafts have a major risk of fungal keratitis due to long-term local and sometimes systemic steroid/antibiotic use. The aim of this study was to evaluate the efficacy of intrastromal voriconazole as a therapeutic adjunctive for the management of fungal keratitis in corneal graft. Design: Presentation of two cases of fungal keratitis occurring after corneal transplantation and treated at the University Eye Hospital “Svjetlost”. Participants and Methods: Two cases of postkeratoplasty fungal keratitis are presented in the study. Both patients had decreased visual acuity, eye redness and severe pain occurring at 10 and 12 months after uneventful corneal transplantation. They were still receiving steroid/antibiotic topical treatment to protect their corneal graft. Patients presented with a stromal infiltrate in a donor tissue, accompanied with corneal ulcer at recipient/donor junction. Candida infection was proven by corneal scraping. Topical and systemic antimycotic treatment was started, fortified by intrastromal injection of voriconazole (50 μg/0.1 ml) given all around the junction of clear cornea and infiltrate (or ulcer). Results: One week after injection, corneal ulcers had healed and corneal infiltrates decreased; resulting in visual acuity improvement from 20/100 to 20/20 in first, and from 20/80 to 20/40 in a second case. One year after infection visual acuity in the first case remained 20/20, and improved to 20/20 in a second case. Conclusion: Intrastromal voriconazole seems to be a safe method for providing a higher concentration of the drug in the cornea affected by fungal keratitis; it can serve as an adjunctive treatment to topical and systemic antifungal therapy.

Objective To observe and analyze the fungal species, risk factors and clinical characteristics in patients with fungal keratitis who underwent large-diameter penetrating keratoplasty(LDPK)in order to provide an objective basis for the diagnosis and treatment of fungal keratitis. Methods This was a retrospective case series study. Patients with fungal keratitis who were admitted to Qingdao Eye Hospital from January 2005 to December 2013 and underwent LDPK(graft diameter>9 mm), were selected for follow-up to monitor fungal species infections. One hundred and thirty-two cases(132 eyes)with fungal keratitis, including 82 males and 50 females, underwent LDPK. Of them, there were 76 farmers, 10 workers and 46 in other occupations. Data on the duration from the onset to the hospital visit, severity at diagnosis and clinical features of infection(including pseudopodia, satellite lesions, endothelial plaque, moss cover, hypopyon, ulcer area)were recorded. A descriptive and statistical analysis(χ2 test)was performed on the differences in species and the relationship between the differences in clinical features. Results The infectious fungal species included 85 cases of Fusarium(64.4%), 10 cases of genus Aspergillus(7.6%), and 37 other cases. The mean duration from onset to LDPK surgery in all 132 cases was 23.7 ± 11.2 days. The first three clinical features of Fusarium spp. were pseudopodia, hypopyon and satellite lesions; the first three clinical features of Aspergillus spp. were hypopyon, moss cover and pseudopodia. Compared with Aspergillus spp.(44.8±20.2 mm2), the ulcer area of Fusarium spp.(48.3±12.3 mm2)was larger, and occupied the entire cornea in 29 patients with Fusarium spp. Conclusion Fusarium spp. and Aspergillus spp. are common pathogenic fungi and may cause serious fungal infections that threaten eyeball preservation. The large amount of hypopyon is an important indicator of serious fungal infections. For patients poorly controlled with drugs, the early selection of corneal transplant surgery for disease control may provide a positive clinical treatment strategy. Key words: Fungal keratitis; Fungal species; Clinical manifestations; Risk factors

Severe fungal keratitis caused by Lasiodiplodia theobromae following grass trimmer–related ocular trauma: a case report

Risk Factors, Clinical Features, and Outcomes of Recurrent Fungal Keratitis after Corneal Transplantation

Keratomycosis is a significant cause of mono-ocular blindness, especially in tropical regions. Fungal keratitis developing in corneal incisions is very rare. We report the experience of treating two patients diagnosed with recalcitrant candida keratitis post-phacoemulsification with anterior chamber washout and deep debridement. The first patient was a 68-year-old woman who underwent left eye phacoemulsification nine months ago with a postoperative best corrected visual acuity of 6/6. The second patient was a 73-year-old man who had uneventful right eye phacoemulsification six months prior with a postoperative best corrected visual acuity of 6/9. Both patients used topical steroids postoperatively for more than three months and noted a drop in vision. Both patients had deep stromal infiltration and endothelial plaque at the primary corneal wound. They were unresponsive to topical, intracameral, and systemic antifungal therapy. Both patients underwent anterior chamber evacuation of hypopyon and endothelial plaque removal. Evacuation of hypopyon and removal of endothelial plaque was done with a 23G vitrectomy cutter using a low-powered vacuum controlled at 200 mmHg. The fluid inside the tubing was sent for culture analysis. We used viscoelastic coating on the endothelium to minimize the damage during the operations. Intracameral amphotericin B 15 µg/0.1 ml was given at the end of the operation. Postoperatively, both patients had clear corneas. The first patient’s visual acuity improved 6/18, and the second patient’s visual acuity improved to 6/9. Both cultures isolated Candida parapsilosis sensitive to amphotericin. These patient cases highlight that evacuation of the anterior chamber infiltration in recalcitrant fungal keratitis and intracameral injection of amphotericin B can be an effective adjuvant therapy.

Purpose: To describe a case of fungal keratitis caused by Zygomycota, diagnosed using confocal microscopy, and its clinical management.Methods: Case report.Results: The patient was an 18-year-old Taiwanese female with no past history of ocular trauma. Recently, she had been wearing soft contact lenses when swimming, and she experienced redness, photophobia, and painful sensations of the left eye for the past 3 weeks. Before hospitalization, she suffered from rapidly decreasing visual acuity of the left eye. The best-corrected visual acuity were 6/6 in the right eye and hand movement in the left eye. Slit-lamp examination showed serious central corneal infiltration and ulceration of the left eye. Microscopy with potassium hydroxide (KOH) staining of corneal scrapings revealed aseptate hyphae with sharp right-angle branches. Confocal microscopy confirmed the detailed fungal structure of zygomycota in the anterior stromal layer of the left eye. She received combined topical antifungal and antibiotic therapy. No fungal cultures showed any growth. Fortunately, the patient achieved a good visual outcome after treatment, with a best-corrected visual acuity of 6/12 of the left eye after 6-months' follow-up.Conclusion: Fungal keratitis is usually encountered in the clinic after ocular trauma or inappropriate contact lens wearing. In our case, the KOH stain and confocal microscopy helped us to quickly and accurately diagnose fungal keratitis caused by Zygomycota. Rapid diagnosis, aggressive topical antifungal therapy, and surgical debridement of necrotic material are efficacious at promoting infection control and achieving a good prognosis for visual outcome.

This study highlights the clinical presentation of ring infiltrates (RI) in Pythium keratitis, typically associated with fungal or Acanthamoeba keratitis, emphasizing diagnostic and therapeutic challenges. We present a retrospective case series of seven patients diagnosed with Pythium keratitis who developed RI, either at presentation or during the disease course. Diagnosis was confirmed by microbiological examination, and all patients received antipythium therapy within 1 week of presentation. Among the seven patients, all exhibited RI, leading to diagnostic confusion due to its common association with fungal and Acanthamoeba keratitis. Prompt microbiological confirmation enabled targeted therapy, but initial presentation caused diagnostic challenges, especially in settings without routine microbiological support. RI is not uncommon in Pythium keratitis and can result in misdiagnosis as fungal keratitis, particularly in resource-limited settings. Recognizing RI as a feature of Pythium keratitis and ensuring early microbiological confirmation can enhance diagnostic accuracy and improve patient outcomes.

AimTo evaluate the efficacy of intrastromal voriconazole, as a modality of treatment for management of recalcitrant fungal keratitis.MethodsTwelve patients of smear and/or culture positive fungal keratitis not responding to topical...

BackgroundWe present a case of fungal keratitis caused by Scedosporium apiospermum, which is a rare agent.Case descriptionA 34-year-old Caucasian male patient was admitted to our clinic with complaints of pain and blurred vision in the left eye. The patient had a history of wearing contact lenses for 3 years. According to the Snellen chart, the patient’s visual acuity was 20/20 and counting fingers at 30 cm, for right and left eyes, respectively. A 3 × 3 mm corneal abscess at the center of the cornea with hypopyon in the patient’s left eye was observed. After the patient was hospitalized, fortified gentamicin and fortified cefazolin drops were started 24 times per day. Intravenous fluconazole 1 × 800 mg loading, 1 × 400 mg maintenance dose, intravenous vancomycin 4 × 500 mg and intravenous cefoperazone + sulbactam 2 × 2 g treatments were started. We observed S. apiospermum in the corneal scraping sample, which the identification was performed by combined phenotypic characteristics and matrix-assisted laser-desorption ionization time-of-flight mass spectrometry on the sixth day of treatment. The drops were revised as fortified vancomycin, ceftazidime, and voriconazole drops 24 times per day. Intravenous voriconazole 2 × 6 mg/kg loading and 2 × 4 mg/kg maintenance dose treatments were started. Three weeks later, left eye visual acuity increased to 20/40, and the corneal abscess regressed. On second-year follow-up, his visual acuity increased to 20/25 for the left eye and the cornea was transparent.ConclusionScedosporium group is an opportunistic filamentous fungus that is very rarely seen and causes severe keratitis infections. In the literature, to the best of our knowledge, three cases of keratitis due to S. apiospermum after contact lenses were reported, and all were treated with penetrating keratoplasty. In this case, unlike the others, only medical treatment was applied. In cases with suspected fungal keratitis, medical treatment should be started without waiting for the culture result, the findings should be followed and penetrating keratoplasty should be performed in the case of no response to treatment.

Purpose:To report concurrent Fusarium and Acanthamoeba keratitis associated with contact lens wear and treated with penetrating keratoplasty Methods: A 27 year old woman, presented with a 7 day history of pain, watering and foreign-body sensation in her left eye in the setting of monthly disposable contact lens wear and swimming with lenses in situ. She had been self-treating with combination dexamathasone 0.1% and tobramycin 0.3% drops (Tobradex®). Slit-lamp examination revealed a 1.0 x 1.0 millimetre corneal ulcer with underlying infiltration. Corneal scrapes were performed and hourly Ofloxacillin 0.3% drops commenced. Initially symptoms and signs improved but worsened a week later. The scrapings grew Aspergillus fumigates and she was then referred to the corneal service. Results: At this stage a central stromal infiltrate was observed with surrounding satellite infiltrates. The cornea was re-scraped (as it was felt the Aspergillus culture was the result of a contaminant) and the patient was commenced on hourly Econazole 1% drops and systemic Voriconazole. Three days later, the second scrapings grew Acanthamoeba polyphagia. Intensive Brolene and Polihexamide drops were commenced, in addition to the systemic and topical antifungal treatment. Despite treatment, symptoms and signs of keratitis worsened, vision reduced to light perception and 4 weeks later she underwent a left therapeutic keratectomy. Histological examination of the corneal button revealed fungal hyphae and culture grew Fusarium. Topical anti-protozoal and antifugal therapy and systemic Vorconazole were continued for 8 weeks. Six months following keratoplasty the corneal graft remains clear on a reducing dosage of topical dexamethasone 0.1% with a best corrected visual acuity of 20/30. Conclusion: Concurrent Fusarium and Acanthamoeba keratitis may occur in the setting of contact lens wear and their misuse. Despite intensive appropriate topical and systemic therapy the condition worsened but remained central in location and following therapeutic penetrating keratoplasty resolved.

PurposeThis study aimed to report the use, efficacy, and safety of intracameralvoriconazole as an adjuvant treatment for deep fungal keratitis.MethodsThis was a prospective case series of seven eyes with fungal keratitis withanterior chamber involvement or a corneal ulcer refractory to conventionaltopical treatment. In addition to topical treatment with 0.15% amphotericinB eye drops, voriconazole 50 µg/ 0.1 mL was administered to theanterior chamber of each affected eye up to four times within 72 h. Theprimary outcome measures were healing (fungal eradication) and the need fortherapeutic keratoplasty. Best-corrected visual acuity was a secondaryoutcome measure.ResultsThree cases were confirmed by confocal microscopy, and four were diagnosedfrom positive culture tests. At presentation, one patient had abest-corrected visual acuity of 20/80, while all others had hand motion orworse. Four cases received one intracameral injection, two cases receivedthree, and one case received four injections. There were no complicationsafter any of the intracameral voriconazole injections. Four patients hadimminent corneal perforations and were treated with cyanoacrylate adhesiveand bandage contact lenses. Four patients recovered from the infection, andthree underwent therapeutic keratoplasty. The final best-corrected visualacuity was improved in two cases but all patients had a final visual acuityof counting fingers or worse.ConclusionAs an adjuvant treatment for deep fungal keratitis, intracameral voriconazoleinjection is a feasible option. Although fungal eradication was achieved inall patients, three required therapeutic keratoplasty and all patients hadunsatisfactory visual acuity outcomes.