Feathery Margins Research Articles

Iris melanoma: Review of clinical features, risks, management, and outcomes

Primary uveal melanoma is rare and affects approximately 8,000 persons per year worldwide. This malignancy can involve the iris, ciliary body, and choroid. Of these three structures, the iris is the least commonly affected site, representing only 4% of all uveal melanomas. Iris melanoma can arise from iris melanocytic nevus, iris melanocytosis, or de novo. In a longitudinal study of 1,611 patients with iris nevus, transformation into melanoma, using Kaplan-Meier estimates, was found in 2.6% by five years and in 4.1% by 10 years. The factors that predicted growth of iris melanocytic nevus into melanoma are denoted by a letter (ABCDEF) guide: A for age ≤40 years old at presentation (hazard ratio [HR] = 3, P = .01), B for blood (hyphema) (HR = 9, P < .0004), C for clock hour of tumor inferiorly (tumor location) (HR = 9, P = .03), D for diffuse flat tumor configuration (HR = 14, P = .02), E for ectropion uveae (HR = 4, P = .002), and F for feathery ill-defined margins (HR = 3, P = .02). At diagnosis, iris melanoma has a mean cross-sectional diameter of 5.5 mm and thickness of 2.1 mm, often with tumor seeding (28%) and secondary glaucoma (35%). We provide a comprehensive review of iris nevus and melanoma to explore relevant demographic and clinical data, risk factors for tumor growth, management, and prognosis, with the hope that clinicians will be more comfortable in understanding this rare malignant condition.

A CLINICAL STUDY ON KERATOMYCOSIS IN PATIENTS ATTENDING TERTIARY CARE HOSPITAL

AIM : To study etiology , epidemiological factors leading to keratomycosis in various subgroups of population like different age and sex groups. To determine spectrum of ocular manifestations in patients with keratomycosis. METHODS : This is a prospective study done in 100 patients of fungal keratitis over a period of 1 year with proper recordings of snellens visual acuity chart, slit lamp biomicroscopy, direct and indirect ophthalmoscopy, conrmed by culture, histology and confocal microscopy, PCR, in patients attending tertiary care hospital , kakinada. This study was conducted in 100 pati RESULTS : ents , of most common age group was 31-40 years i.e, which most exposed to trauma to cornea with vegetative matter, immunocompromised people, over usage of steroids and antibiotics and many factors. Males are more affected and among agricultural workers with mostly unilateral in presentation. Majority presented with pain, redness , foreign body sensations, defective vision. Ulcer is dirty looking, feathery margins with wessely ring and satellite lesions. CONCLUSION: Fungal infections of cornea continue to be an important cause of ocular morbidity, particularly in the communities of agriculture of developing countries. A proper understanding of agent and host factors involved in these infections will improve the outcome of this condition.

Role of intracameral Caspofungin in the management of Aspergillus keratitis: A case report

Abstract A 48-year-old male patient with a history of fall of dust in his right eye while driving came for a second opinion. On examination, he had a dry-looking ulcer with feathery margins and a hypopyon, suggestive of fungal keratitis. Scraping showed septate fungal filaments. Aspergillus niger grew in culture, and the patient was asked to use frequent natamycin eye drops. However, the hypopyon continued to increase, so ketoconazole tablets were added. Intracameral injection of Amphotericin B was advised, but in view of a severe shortage of the drug in the region, injection of Caspofungin (CAS) was given intracamerally with patient consent. With a combination of oral, topical, and intracameral antifungal medication, the ulcer slowly resolved over a period of 1 month, leaving behind a nebulomacular corneal scar in a quiet eye. Intracameral CAS may provide a safe and effective alternative to voriconazole and amphotericin B in the setting of Aspergillus keratitis.

Post-traumatic orbital subperiosteal hematoma presenting as proptosis with Curvularia keratitis

A 13-year child presented with protrusion of the left eye (LE) with redness, pain, and diminution of vision following blunt head trauma. The best-corrected visual acuity (BCVA) in the LE was hand movement. On examination, LE had abaxial proptosis with lagophthalmos and severe exposure keratopathy. There was a large corneal ulcer with feathery margins and superficial brown pigmentation, confirmed as Curvularia spp. on microbiological assessment. A computed tomography (CT) scan of the orbit and brain demonstrated superior subperiosteal hematoma of the orbit and frontal epidural hematoma. Aspiration of blood from subperiosteal orbital hematoma resulted in an immediate reduction of proptosis. The epidural hematoma resolved spontaneously. Treatment with topical and systemic antifungal agents resulted in complete healing of the keratitis with a residual leucomatous corneal opacity. Emergency treatment of subperiosteal orbital hematoma through needle aspiration helps in the early resolution of proptosis, exposure keratopathy, and visual loss.

P231 The first case of neonatal fungemia caused by Aureobasidium melanogenum

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Background Aureobasidium melanogenum is a ubiquitous, saprophytic, dematiaceous fungus commonly isolated from environmental sources. It has the highest virulence potential among all Aureobasidium species and is implicated in catheter-related infections, particularly in immunocompromised hosts.Case ReportA 6-day-old female child was admitted to the neonatal intensive care unit (NICU), AIIMS, Jodhpur with respiratory distress, hypotension, bradycardia, and sepsis. The baby was preterm with a very low birth weight (1140 g) and was born to a 34-year-old G3P1A2 mother at 30 weeks gestation by elective caesarian section at a private hospital. The mother had a primary ovarian failure and had a history of spontaneous abortions for two consecutive times following in vitro fertilization. She also had a history of gestational diabetes mellitus and pregnancy-induced hypertension, for which she was on medication. At birth, the baby had respiratory distress (Apgar scores were 6 and 7 at 1 and 5 minutes of life, respectively), for which she was shifted to NICU and intubated. On day 2, she developed hypotension, bradycardia, hypocalcemia, and sepsis with deranged coagulation profile, for which she received inotropes, broad-spectrum antibiotics, fluconazole, and fresh frozen plasma. On day 3, the baby developed chest retractions and seizure-like episodes with intermittent myoclonic jerks and was started on anti-epileptics. She had persistently raised serum urea, creatinine, and C-reactive protein from day 3 of life. Due to clinical deterioration, she was shifted to AIIMS NICU for further management where she was continued on inotropes, broad-spectrum antibiotics, and fluconazole. After 46 h of admission at AIIMS NICU, the baby developed hypotension with cold extremities, feeble pulses, and increased ventilatory requirements. Chest X-ray showed bilateral diffuse infiltrates suggestive of acute respiratory distress syndrome. Culture of tracheal aspirate yielded Klebsiella pneumoniae, sensitive to piperacillin/tazobactam, amikacin, and carbapenems. The patient was started on intravenous meropenem and colistin. Blood culture showed growth of Gram-positive budding yeast cells after 48 h of incubation (Fig. 1). Subculture on Sabouraud dextrose agar revealed yeast-like colonies, initially cream-colored, becoming dark-brown with an olive-green feathery margin (Fig. 2a). Microscopically, the isolate had septate pigmented hyphae with ellipsoidal hyaline conidia (Fig. 2b). The morphologic features were consistent with Aureobasidium species. Sequencing the internal transcribed spacer region of rDNA confirmed the identity of the isolate as A. melanogenum. Antifungal susceptibility testing revealed the following MICs: amphotericin B, 0.5 μg/ml, itraconazole, 0.25 μg/ml, voriconazole, 0.125 μg/ml, fluconazole, 16 μg/ml, and caspofungin, 0.25 μg/ml. Despite maximum inotropic and ventilatory support, the baby had persistent desaturations and hypoxia and developed multiple organ dysfunction syndrome, following which she succumbed to death on day 3 of admission to AIIMS.ConclusionThis is the first documented case of neonatal fungemia caused by the emerging yeast A. melanogenum. The patient had multiple arterial and intravenous catheters and this could be the portal of entry of the pathogen. Accurate identification is crucial for initiating appropriate antifungal therapy. Physicians should be mindful of possible A. melanogenum infection in patients with risk factors, and provide appropriate antifungal therapy with the removal of indwelling catheters whenever possible.

Exserohilum rostratum keratitis: report of a case from South Africa

We report a case of infectious keratitis caused by the fungal pathogen Exserohilum rostratum in an immune-competent patient in South Africa. A 67-year-old man with hypertension presented with a painful red left eye two weeks after trauma with an organic foreign body. Slit-lamp biomicroscopy revealed a corneal ulcer with underlying stromal infiltrates, feathery margins and a hypopyon. Exserohilum rostratum was identified using fungal PCR testing on culture grown from a corneal scrape, and the patient responded to topical 5% natamycin eye drops. Corneal scarring limited final visual outcomes to Counting Fingers at 50cm. In conclusion, E. rostratum keratitis was previously rare, but is now considered an emerging corneal pathogen which can occur in temperate climates.

Henle fibre layer haemorrhage: clinical features and pathogenesis

BackgroundTo describe the clinical presentation and characteristic imaging features of deep retinal haemorrhages primarily located in the Henle fibre layer (HFL) of the macula. The spectrum of aetiologies and a...

Epidemiology, risk factors, and clinical outcomes in severe microbial keratitis in South India

ABSTRACTPurpose: Here, we report risk factors associated with outcome in severe bacterial keratitis (BK), fungal keratitis (FK), and Acanthamoeba keratitis (AK) in India.Methods: Prospective observational cohort study conducted in Aravind Eye Hospital, India. Adults presenting with severe microbial keratitis (MK) were enrolled (size ≥3 mm) and followed to 21 days post-enrolment. Ulcer clinical features were recorded at presentation. Outcomes by final visit were classified as good (completely healed or reduced infiltrate size) or poor (enlarged infiltrate size, perforated, or surgery performed).Results: Of 252 participants with severe MK, 191 had FK, 18 had AK, 19 had BK, 4 had mixed BK/FK, and 20 were microbiologically negative. Median age was 50 years (interquartile range [IQR]: 37–60 years), 64% were male, 63% were agriculturalists, and 45% had no formal education. Corneal trauma occurred in 72%, and median symptom duration before presentation was 7 days (IQR: 5–15 days). Clinical features associated with FK were feathery margins (p < 0.001), raised profile (p = 0.039), or dry surface (p = 0.007). Hypopyon was more likely in BK (p = 0.001) and ring infiltrate in AK (p < 0.001). Ulcers with poor outcome (n = 106/214) were more likely to be larger (odds ratio [OR]: 1.63, 95% confidence interval [CI]: 1.30–2.05, p < 0.001), involve the posterior cornea at presentation (OR: 2.31, 95% CI: 1.16–4.59, p = 0.017), involve Aspergillus sp. (OR: 3.23, 95% CI: 1.26–8.25, p = 0.014), or occur in females (OR: 2.04, 95% CI: 1.03–4.04, p = 0.04). Even after treatment, 34% (n = 76/221) had severe visual impairment by the final visit.Conclusions: Severe MK occurred predominantly in agriculturalists post-corneal trauma and often had poor outcomes. Provision of community-based eyecare may allow earlier treatment and improve outcomes.

Diagnosis and Therapy of Iris Lesions

The most common iris lesions are iris nevi, iris melanomas and iris pigment epithelium cysts. However, there is an abundance of rare differential diagnoses that have to be considered, including other melanocytic and non-melanocytic lesions. Diagnostic tools include the slit lamp examination, gonioscopy, tonometry, transillumination, ultrasound biomicroscopy (UBM), optical coherence tomography, fluorescein angiography and standardized photography-assisted documentation. The timely identification of malignant lesions (i.e. iris melanoma) is paramount. To assess malignancy criteria of iris nevi, the ABCDEF rule (age young, blood, clock hour inferior, diffuse growth, ektropion uveae, feathery margins) can be applied. Statistically, up to 11% of iris nevi may develop into iris melanomas within 20 years. TNM Staging follows the 2010 AJCC cancer staging manual and helps determine the optimal treatment strategy. Treatment options include radiotherapy, such as plaque brachytherapy and proton beam radiation therapy, as well as surgical excision. Both the surgical and the radiotherapeutic approaches show comparable local tumor control rates. However, the spectrum of therapy-related side effects and complications may differ amongst treatment modalities. After initial treatment, patients should be followed up every 3 - 6 months. Tumor-related mortality ranges between 0 - 11% and is significantly lower than in other uveal melanomas. A prognostic value of common genetic alterations, which have been identified as significant prognostic factors in posterior uveal melanoma, could not be shown for iris melanoma.

Diagnostik und Therapie von Irisläsionen

ZusammenfassungTeil des klinisch-ophthalmologischen Alltags ist die korrekte Diagnose tumoröser Irisläsionen. Insbesondere die Differenzialdiagnose und die Bewertung der Dignität anhand der Morphologie gestalten sich dabei oft schwierig. Dieser Beitrag gibt einen Überblick über das breite Spektrum von Iristumoren einschließlich empfohlener Diagnostik- und Therapiemodalitäten.

Fungal Keratitis Caused By Epicoccum Sorghi – A Case Report

A 40 year old male presented with redness, pain and watering in his right eye since 3 days. He did not give any history of ocular trauma. A slit lamp evaluation showed a corneal ulcer with feathery margins suggestive of fungal keratitis which was confirmed by microscopic evaluation of the corneal smear. The species of the organism could not be identified by conventional phenotypic methods. A subsequent DNA sequencing identified it to be Epicoccum sorghi, a known plant pathogen. The keratitis healed with topical voriconazole (1%) eye drops in about 4 weeks with a residual scar.

Melanoma of the eye: Revealing hidden secrets, one at a time

Melanoma of the eye can involve the uveal tract with iris, ciliary body, or choroid involvement or it can involve the conjunctiva, eyelid, or orbit. Uveal involvement with choroidal melanoma is the most common, found in light complexion Caucasians with an age-adjusted incidence of 4.3 per million persons. Early detection of uveal melanoma is critical. The ABCDEF guide helps to differentiate iris nevus from iris melanoma. The letters represent: A, age young (≤40 years); B, blood in anterior chamber; C, clock hour of mass inferiorly; D, diffuse configuration; E, ectropion; and F, feathery margins. The mnemonic of TFSOM-UHHD (To Find Small Ocular Melanoma—Using Helpful Hints Daily) helps to differentiate choroidal nevus from small melanoma and represents: T, thickness over 2 mm; F, fluid; S, symptoms; O, orange pigment; M, margin within 3 mm of the optic disc; UH, ultrasound hollow; H, halo absent; and D, drusen absent. Patients with 3 or more of these factors are likely to have melanoma. These key clinical features help to identify small melanoma at a time when therapy could be life-saving.Conjunctival melanoma usually arises from primary acquired melanosis, a flat pigmentation that can lead to melanoma. Wide excision using no touch strategy is important to tumor control. Ocular examination is advised annually for all persons for detection of refractive error, cataract, glaucoma, and other conditions, but also for the detection of asymptomatic malignancies like melanoma. One at a time, we have uncovered the secrets of ocular melanoma and we forge ahead with the goal to solve the riddle of this challenging disease.

A case of fungal keratitis and onychomycosis simultaneously infected by Trichophyton species

BackgroundFungal keratitis is difficult to treat that can result in corneal blindness requiring penetrating keratoplasty and in fungal endothalmitis. We report a case of fungal keratitis and onychomycosis simultaneously infected by Trichophyton.Case presentationA 77-year old male presented with ocular pain, conjunctival injection, and severe loss of vision in his left eye. His best corrected visual acuity was hand movements in the left eye, and slit-lamp examination showed a corneal ulcer with feathery margin and hypopyon. Bacterial and fungal smear/culture showed no organism, and there was no improvement in spite of treatment with topical fortified 5% cefazolin and 2% tobramycin. Trichophyton species was identified by repeated cultures. We found onychomycosis on the patient’s foot, where the same fungal species were identified. Regimen was changed to topical itraconazole and systemic intravenous itraconazole. No clinical improvement was observed, so therapeutic penetrating keratoplasty and cryotherapy was done with continuation of antifungal therapy. The graft was clear at postoperative 1 month and no evidence of recurrence was found.ConclusionIt is important to identify the pathogen of keratitis because early identification of pathogen causing keratitis provides the appropriate treatment in early phase of keratitis. It is necessary to search for other fungal skin infections such as onychomycosis and athelete’s foot considering the fungal keratitis following skin infection. In addition, fungal skin infection including onychomycosis should be treated for prevention of fungal keratitis as soon as possible.

A profile of corneal ulcers – 2 years study from rural hospital, Haryana

Corneal ulceration is a leading cause of ocular morbidity and blindness worldwide. The present study was carried out by the Department of Microbiology & Ophthalmology, MMIMSR, on 60 corneal scraping samples from clinically suggested cases of corneal ulcers. Corneal scrapings were collected and subjected to microscopy and culture. Out of the 60 patients suspected of having bacterial and fungal keratitis, 43.3% were found to be culture positive. Rate of detection of bacterial and fungal and mixed growth was 30.76%, 61.53% and 7.69% respectively. Ocular trauma (68.3%) was the most common predisposing factor followed by Topical steroids (14.6%) and Diabetes mellitus (7.31%). Sugarcane leaf accounted for (37.5%) cases followed by paddy leaf, wood chip and iron piece which accounted for (12.5%) cases each. Among the clinical features, redness 81.25%), blurred/diminished vision (81.25%), pain (68.7%), irregular feathery margins (75%) was most commonly seen in fungal keratitis while Pain (75%), redness (87.5%), lacrimation (62.5%), hypopyon (37.5%) was most commonly seen in bacterial keratitis. Accurate diagnostic tests not only play a key role in patient management but also reduce the risk of the patient developing long-term complications. The definitive diagnosis of ulcers caused by multiple organisms can only be arrived at by microbiological evaluation. Keywords: Corneal ulcer, Clinical presentations, Microbiological diagnosis, Ocular morbidity.

MRI patterns of T1 enhancing radiation necrosis versus tumour recurrence in high‐grade gliomas

Despite the emergence of new imaging technologies, the differentiation of treatment-related changes from recurrent tumour in patients with high-grade gliomas remains a difficult challenge. We evaluated whether specific MRI (magnetic resonance imaging) T1 post-contrast enhancement patterns can help to distinguish between radiation necrosis and tumour recurrence. This study was approved by local institutional review board. Fifty-one patients with World Health Organization grade III-IV glioma underwent reoperation after prior chemoradiation. The percentage of radiation necrosis versus recurrent tumour in reoperation specimens was estimated by an experienced neuropathologist. Enhancement patterns on T1 post-contrast sequences from the MRIs obtained prior to reoperation were evaluated according to pathology. T1 contrast enhancement patterns correlating with recurrent tumour included focal solid nodules and solid uniform enhancement with distinct margins. Eighty-five per cent (17/20) of patients with ≥70% recurrent tumour at reoperation demonstrated one of these patterns on preoperative MRI. Enhancement patterns correlating with radiation necrosis included a hazy mesh-like diffuse enhancement and rim enhancement with feathery indistinct margins. Ninety-four per cent (17/18) of patients with ≥70% radiation necrosis demonstrated one of these two patterns. Thirteen cases had more mixed pathology (>30% of tumour/necrosis) and demonstrated patterns associated with recurrence and/or necrosis. Compared to MR spectroscopy performed in 10 patients, enhancement patterns on MRI were just as accurate in predicting pathologic diagnosis. Identifying distinct patterns of contrast enhancement on MRI may help to differentiate between radiation necrosis and tumour recurrence in high-grade gliomas.

Iris Nevus Growth into Melanoma: Analysis of 1611 Consecutive Eyes: The ABCDEF Guide

To determine clinical features predictive of growth of iris nevus into melanoma. Retrospective, comparative case series. A total of 1611 consecutive patients referred to an ocular oncology center with iris nevus. Observation and photographic documentation. Growth into melanoma. The mean age at referral for iris nevus was 51 years (median, 54; range, <1-94 years). At presentation, the mean tumor basal diameter was 3 mm (median, 3 mm; range, <1-12 mm) and mean tumor thickness was 0.8 mm (median, 0.5 mm; range, 0-5 mm). All patients were initially diagnosed with benign iris nevus. Growth of iris nevus to melanoma was confirmed in 2% of eyes (n = 27) over a mean follow-up of 68 months (median, 46 months; range, 3-465 months). By Kaplan-Meier estimates, iris nevus growth to melanoma occurred in <1%, 3%, 4%, 8%, and 11% at 1, 5, 10, 15, and 20 years, respectively. Factors predictive of iris nevus growth to melanoma by multivariable analysis included age ≤ 40 years at presentation (hazard ratio [HR], 3), episode of hyphema (HR, 9), 4:00 to 9:00 clock hour location of tumor (HR, 9), diffuse tumor (involving entire iris surface) (HR, 14), ectropion uveae (HR, 4), and feathery tumor margins (HR, 3). Additional important factors by univariable analysis included tumor seeding on the iris or in the anterior chamber angle, feeder vessels, and nodule formation. These factors can be remembered using the mnemonic ABCDEF, representing A = age young, B = blood, C = clock hour inferior, D = diffuse, E = ectropion, and F = feathery margin. In an analysis of 1611 cases of iris nevus referred for evaluation at an ocular oncology center, growth into melanoma occurred in 8% by 15 years. Risk factors for growth, identified by ABCDEF included Age young, Blood (hyphema), Clock hour inferior, Diffuse configuration, Ectropion uveae, and Feathery tumor margin.

Review of cystic and solid tumors of the iris

Iris tumors are broadly classified into cystic or solid lesions. The cystic lesions arise from iris pigment epithelium (IPE) or iris stroma. IPE cysts classically remain stable without need for intervention. Iris stromal cyst, especially those in newborns, usually requires therapy of aspiration, possibly with alcohol-induced sclerosis, or surgical resection. The solid tumors included melanocytic and nonmelanocytic lesions. The melanocytic iris tumors include freckle, nevus (including melanocytoma), Lisch nodule, and melanoma. Information from a tertiary referral center revealed that transformation of suspicious iris nevus to melanoma occurred in 4% by 10 years and 11% by 20 years. Risk factors for transformation of iris nevus to melanoma can be remembered using the ABCDEF guide as follows: A=age young (<40 years), B=blood (hyphema) in anterior chamber, C=clock hour of mass inferiorly, D=diffuse configuration, E=ectropion, F=feathery margins. The most powerful factors are diffuse growth pattern and hyphema. Tumor seeding into the anterior chamber angle and onto the iris stroma are also important. The nonmelanocytic iris tumors are relatively uncommon and included categories of choristomatous, vascular, fibrous, neural, myogenic, epithelial, xanthomatous, metastatic, lymphoid, leukemic, secondary, and non-neoplastic simulators. Overall, the most common diagnoses in a clinical series include nevus, IPE cyst, and melanoma. In summary, iris tumors comprise a wide spectrum including mostly iris nevus, IPE cyst, and iris melanoma. Risk factors estimating transformation of iris nevus to melanoma can be remembered by the ABCDEF guide.

Resistance to Benzimidazole Fungicides in the Cereal Eyespot Pathogen,Pseudocercosporella herpotrichoides,in the Pacific Northwest 1984 to 1990

Isolates of Pseudocercosporella herpotrichoides resistant to benzimidazole fungicides were detected in commercial winter wheat fields in the Pacific Northwest region (Washington, Oregon, and Idaho) of the United States for the first time in the spring of 1989. Benzimidazole-resistant isolates were found in nine of 62 fields sampled in 1989 and in 17 of 167 fields sampled in 1990, which represents 24 and 19% of those fields yielding the pathogen, respectively. In 1989 and 1990, respectively, 96 and 70% of all isolates collected from fields where fungicide resistance was detected were resistant to the benzimidazole fungicides. All fields where fungicide-resistant strains of the eyespot fungus were found had at least four previous applications of a benzimidazole fungicide. In 1989 and 1990, respectively, 24 and 15% of the P herpotrichoides cultures collected had a slow growth rate with feathery colony margins on potato-dextrose agar and corresponded to rye-type isolates. However, benzimidazole-resistant rye-type isolates represented only 7 and 4% of the total resistant isolates collected in 1989 and 1990, respectively.

The Changing Spectrum of Fungal Keratitis in South Florida

To review the clinical experience with fungal keratitis in south Florida over a 10-year period. One hundred twenty-five cases of fungal keratitis were identified in the microbiology laboratory records between January 1982 and January 1992. The medical record of each patient was reviewed. The most commonly associated risk factor was trauma (44%). Fungal keratitis developed in five patients using extended wear contact lenses and one patient wearing a therapeutic bandage contact lens. Clinical features included irregular, feathery margins (62%), a dry, rough texture (47%), and satellite lesions (41%). An initial positive culture was obtained in 90% of patients, with a majority of cultures becoming positive within 48 hours. The Fusarium sp accounted for 62% of the isolates, with Fusarium oxysporum being the most commonly isolated organism. New fungal isolates include Candida parapsilosis, Aspergillus terreus, Candida tropicalis, and Trichosporon beigellii. Natamycin 5% suspension was the initial antifungal agent used for 91% of the patients, with an average duration of treatment of 38 days. Twenty-five patients were treated with oral ketoconazole for a median duration of 2 weeks, in addition to topical antifungal therapy. Thirty-four patients (27%) required a penetrating keratoplasty. Six patients had recurrence of fungal keratitis after penetrating keratoplasty. Trauma, including contact lens wear, is the most commonly associated risk factor. The fungal organisms can be readily identified in culture. F. oxysporum is the most common organism, with new isolates identified. The mainstay of therapy is topical natamycin with the increasing use of imidazoles.

Das kombinierte Hamartom der Retina und des retinalen Pigmentepithels - Klinik und Differentialdiagnose zu anderen melanozytären Prozessen des Fundus

The combined hamartoma of the retina and the retinal pigment epithelium is a rare but important differential diagnosis of the melanocytic lesions of the fundus. We present a patient with the typical clinical picture and characteristic fluorescein angiography findings. The case report is followed by the discussion of the differential diagnoses and their specific signs. The combined hamartoma of the retina and the retinal pigment epithelium is a congenital malformation without growth potential, which may lead to a slow reduction of visual acuity due to secondary changes in the vitreoretinal interface followed by retinal traction. The hamartoma shows a typical clinical picture: unnoticed reduction of visual acuity, grayish tumor on the level of the retina with feathery margins, secondary epiretinal proliferation and traction of the neurosensory retina. The fluorescein angiography findings are pathognomonical for the hamartoma: early blockage of the choroidal hyperfluorescence due to the pigmentation of the tumor, a fine network of abnormal retinal capillaries with leakage, epiretinal traction, tortuositas of the larger retinal vessels without leakage. The retinal and pigmentepithelial hamartoma can be diagnosed in most of the cases by mere visual inspection. The diagnosis can be confirmed by fluorescein angiography and always has to be included to evaluate the differential diagnoses of all pigmented fundus lesions.