Microsporidial Keratoconjunctivitis Research Articles

Successful Treatment of Microsporidial Keratoconjunctivitis (MKC) With a Combination of Topical Voriconazole 1% and Gatifloxacin 0.5%: A Large Case Series of 29 Patients.

This study aims to report the successful treatment of microsporidial keratoconjunctivitis (MKC) with the combination of topical drops of voriconazole (1%) and gatifloxacin (0.5%) in all 29 patients. Demography, clinical profile, and previous treatment history were also analyzed. A retrospective, non-comparative case series of all Gram stain-proven MKC from September 2021 to October 2022 was included in this study. Patients were given antimicrobials such as topical drops of voriconazole 1%, gatifloxacin 0.5%, or a combination of both in 29 patients based on the treatment response. Topical steroids were added to 31 patients for corneal haziness. A total of 33 patients were found to be positive for microsporidiosis confirmed by Gram staining. Twenty-four (72.7%) were men and nine (27.3%) were women. The mean age was 34.45±12. The presenting symptoms were mainly redness in 30 patients (90.9%), followed by watering in 13 (39.4%), foreign body sensation in 10 (30.3%), etc. Among the 23 patients (69%), a history of risk factors was identified, with 17 patients (51.5%) specifically reporting dust exposure as a major cause. MKCs were successfully treated with antimicrobials such as voriconazole 1% in three patients, gatifloxacin 0.5% in one patient, and a combination of both in 29 patients. Topical steroids were added to 31 patients for corneal haziness. At the last follow-up, a visually insignificant nummular corneal scar was noted in six patients. No drop in vision was noted in any of these patients at the end of the follow-up. No cases progressed to stromal keratitis and no surgical intervention was required in any cases. We successfully treated all 29 cases with a combination of voriconazole and gatifloxacin without requiring any surgical intervention or encountering stromal complications. This successful treatment in all 29 cases offers valuable insights into the potential of this drug combination, possibly attributable to its additive action or broad-spectrum coverage across various species.

Microsporidial keratoconjunctivitis - first outbreak in Japan.

Most cases of microsporidial keratoconjunctivitis are found in the Southern hemisphere. Our purpose was to investigate the first outbreak of microsporidial keratoconjunctivitis in Japan among healthy, immunocompetent soccer players from the same team during a 1-month period. This study is an observational case series. The medical records were analyzed for five cases with microsporidial keratoconjunctivitis who presented within September 2022. All five cases were males between 28 and 36 years old. These previously healthy individuals belonged to the same football team. Their eyes were considered susceptible to contaminated water or dirt from the turf at game and practice sites. All cases involved unilateral conjunctivitis, with scattered round white lesions that showed positive fluorescein staining in the corneal epithelium. All cases experienced diminution of vision in the affected eye. In three cases, direct smears showed spores of approximately 2-3μm in diameter. Polymerase chain reaction (PCR) analysis of corneal scrapes revealed partial amplification of microsporidial 18S ribosomal RNA gene in four cases. Sequences of PCR products from all four cases showed 100% identity with strains of Vittaforma corneae previously reported from an outbreak in Singapore. All cases were treated with topical therapy, including voriconazole, fluorometholone, and levofloxacin. Four eyes underwent corneal scraping. After treatment, all eyes healed without residual opacities. Only a few sporadic case reports of this disease have previously been reported in Japan. We detected V. corneae in our case series, representing what appears to be the first outbreak of microsporidial keratoconjunctivitis in Japan. Exposure to contaminated water or soil, in addition to inadequate sanitary facilities, represents a potential source of infection. Further investigations to clarify the characteristics of microsporidia seem warranted.

Microsporidia-Associated Anterior Uveitis After Keratoconjunctivitis.

The aim of this study was to describe the clinical features and management of uveitis associated with microsporidial keratoconjunctivitis (MKC). The medical records of clinically diagnosed or microbiologically proven patients with MKC between July 2016 and August 2021 were reviewed. Patients with documented evidence of keratic precipitates (KPs) or anterior chamber cells were analyzed for their demography, clinical features, and treatment. Patients with microsporidial stromal keratitis and herpes simplex virus keratouveitis were excluded from the study. Of the 2212 patients reviewed within the study period 171 of 172 eyes (7.7%) had documented evidence of KPs and/or anterior chamber cells. The patients' mean age was 43.8 ± 13.8 years, and there were more men (n = 120). The mean duration of appearance of KPs was 6.9 ± 5.5 days, and 28% (n = 48 of 171) appeared on the day of presentation. Superficial punctate keratitis was central and diffuse in 48 and 49 patients, respectively. The treatment was either lubricant alone (45.3%; 78 eyes) or combined with topical steroids (54.7%; 94 eyes). The mean duration of the resolution was longer in the "corticosteroid" than "no corticosteroid" group: KPs: 15.3 ± 6.5 days versus 12.3 ± 5.8 days ( P = 0.007) and superficial punctate keratitises: 15.4 ± 9.4 days versus 11.7 ± 6.2 days ( P = 0.01). The presenting visual acuity with a pinhole was 0.26 ± 0.26 (logMAR) and it improved to 0.03 ± 0.07 on resolution ( P < 0.0001, paired t test). Uveitis after MKC is a self-limiting entity that often resolves without corticosteroid. One must exercise caution in using steroids in the presence of active corneal lesions.

Microsporidial Keratitis - First Case Series of a Rare Pathogen in the Wake of Flood Disasters of 2022 in Pakistan.

The recent monsoon rains in Pakistan were unprecedented and caused flooding all over Pakistan, especially in Sindh and Balochistan. Following this national disaster, various water-borne and contagious diseases started erupting all over the country. In such a calamity-struck city of Jacobabad, we started receiving cases with a peculiar set of ocular complaints mimicking viral keratoconjunctivitis. Failure to respond to traditional treatment and the unique appearance of these corneal opacities led to a rare diagnosis of Microsporidial Keratoconjunctivitis, which was later confirmed by microscopy and staining of corneal scrapings of the most affected case. In line with published literature, all cases were treated with topical fluoroquinolone and topical anti-fungal therapy, following which the disease was cleared within a week. The disease has seen an upward trend the world over, especially among Asia. To the best of our knowledge, no such cases have been reported in Pakistan as yet. In this case series, we highlightthe strong correlation of emergence of microsporidial keratitis in patients following exposure to pooled water bodies after the monsoon rainy season and floods. Moreover, this report will help create awareness in eye professionals regarding the prevention, timely diagnosis and treatment of these rare and emerging cases. Key Words: Keratitis, Spores, Water-borne diseases, Microsporidia.

Microsporidia-induced stromal keratitis: a new cause of presumed immune stromal (interstitial) keratitis

Background and objectiveTo describe the clinical features, diagnosis and management of immune stromal keratitis/interstitial keratitis (IK) associated with microsporidial epithelial keratitis.MethodsBetween October 2020 and January 2021, medical records of IK...

Past, present, and prospects in microsporidial keratoconjunctivitis- A review

Ocular microsporidiosis comprises two entirely different spectra of disease as keratoconjunctivitis and stromal keratitis. Microsporidial keratoconjunctivitis (MKC) has been increasingly reported in the past two decades, probably due to raised awareness, simpler diagnostic procedures, and a better understanding of the clinical presentation. It is characterized by the presence of raised, coarse, punctate, multifocal, round to oval, greyish-white corneal epithelial lesions which usually evolve into nummular scars before resolution. Conjunctivitis seen is non-purulent and of mild-moderate intensity, with mixed papillary-follicular reaction. The mode of transmission and pathogenesis is poorly understood. Despite lack of inflammatory response, uncommon associations reported were- endotheliitis, corneal edema, limbitis, uveitis, and sub-epithelial infiltrates. There has been no consensus on the management of MKC. It varies from the use of multiple antimicrobial agents to simple lubricants. The majority of the disease goes underdiagnosed or misdiagnosed and treated as adenoviral keratoconjunctivitis, with topical steroids or anti-virals empirically. Changing trends have been noticed in the pattern of infection, possibly with increasing evidence of Vittaforma corneae as causative organisms, previously reported to cause stromal keratitis. An elaborate review of the past and present literature on MKC is provided in this review article, along with gaps in knowledge, and future directions of research.

“A prospective study on the clinical course and proposed morphological classification scheme of microsporidial keratoconjunctivitis.”

ABSTRACT Background and objective: To describe the clinical course and propose a morphological classification scheme of microsporidial keratoconjunctivitis. Methods: This is a prospective study at L V Prasad Eye Institute, Odisha, between August–January (2017–19). Patients of any age or sex, microbiologically proven as microsporidial keratoconjunctivitis were included. Demographic parameters, history, clinical course, and visual outcome were analysed. All received artificial tear substitutes till resolution and topical immunosuppressants used in cases of persisting sub-epithelial infiltrates (SEI) beyond 2 weeks. Results: Fifty-three eyes of 47 cases were included with males, 72.3%. Corneal lesions were classified into 3 morphological types- coarse, ring, and flat-topped (Type1, 2 & 3). Depending upon the location, Type 1 was further sub-divided into peripheral, paracentral, central, and diffuse (Type 1a, b, c & d). The mean age was highest in Type 3(p = .026). Risk factors and prior steroid use were most common in Type 1d. The mean duration of symptom before presentation was longest in Type 3(11.6 ± 3.65) days. Severe conjunctival congestion at presentation in more than half of the eyes were seen in Type 1a, 1b and 1d, with moderate congestion at Day14 persisting in 66.7% and 40% of eyes belonging to Type 1c and 1d, respectively. Keratic precipitates were most common in Type 2. The mean duration of resolution was longest in Type 1d (38 ± 15.87) days and shortest in type 1b (7.88 ± 2.47) days (p = .022). Persistent SEIs beyond Day 90 were seen in total of 6 (11.3%) (Type 1c & 1d- 3 each) eyes and recurrent SEIs in 7(13.2%) (Type 1c-2 & 1d- 5) eyes. The mean duration of topical steroids use was longest in Type 1d (49.3 ± 22.3) days, followed by Type 1c (28 ± 0) days. Conclusion: Microsporidial keratoconjunctivitis can have a variable clinical presentation, the course of each being different depending on the host and ocular surface factors. Though considered as a self-limiting disease, central and diffuse coarse variety (Type1c&1d) required long-term topical immunosuppressants and follow-up.

Temporal trend of microsporidial keratoconjunctivitis and correlation with environmental and air pollution factors in India.

Purpose:The aim of this study was to describe the correlation between the temporal pattern of presentation of acute microsporidial keratoconjunctivitis (MKC) with meteorological parameters such as environmental temperature, rainfall, humidity, windspeed, and air pollution.Methods:This cross-sectional hospital-based study included 182,789 patients presenting between January 2016 and December 2019 hailing from the district of Hyderabad. Patients with a clinical diagnosis of MKC in at least one eye with an acute onset (≤1 week) of presentation were included as cases. Correlation analysis was performed with the local environmental temperature, rainfall, humidity, and windspeed (Telangana State Development and Planning Society) and air pollution (Central Pollution Control Board, Government of India).Results:Overall, 84 (0.05%) patients were diagnosed with acute onset MKC from the district of Hyderabad. The mean monthly prevalence in this cohort was 0.05% with peak prevalence in the months of July (0.08%), August (0.09%), September (0.12%), and October (0.08%). The environmental parameters of rainfall (r2 = 0.87/P = < 0.0001), humidity (r2 = 0.78/P = 0.0001), windspeed (r2 = 0.38/P = 0.0321) were significantly positively correlated and the air pollution parameters such as ground level ozone (r2 = 0.89/P = < 0.0001), particulate matter PM10 (r2 = 0.65/P = 0.0013), PM2.5 (r2 = 0.50/P = 0.0095), nitrogen dioxide (r2 = 0.53/P = 0.0071), and carbon monoxide (r2 = 0.69/P = 0.0008) were significantly negatively correlated with the temporal pattern of MKC in the population.Conclusion:Parasitic infections like MKC show a distinct temporal trend peaking during the monsoon season in the population. An increase in humidity, wind speed, and especially rainfall contributes to a higher prevalence of MKC cases during the year. An increase in ground-level ozone seems to be protective against infection.

Sequelae of microsporidial keratoconjunctivitis and its management.

Purpose:To characterize the sequelae of microsporidia keratoconjunctivitis (MKC) and outline its management.Methods:Retrospective analysis of microbiologically proven MKC returned with persistent disease between January 2015 and December 2019 was done. Demographics, clinical features, management, and outcome were analyzed.Results:Sixteen patients (21 eyes) of 332 treated for MKC returned with the persisting disease. The mean age of 11 males (68.7%), and 5 females was 35.1 ± 12.2 years. Three-quarter of them did not have a known predisposing risk factor and one-quarter of them were referred for chronic conjunctivitis. Past medications included topical antivirals (n = 8) and topical corticosteroid (n = 6). Three predominant presentations were persistent (>3 weeks) superficial punctate keratitis (SPKs, n = 7), sub-epithelial infiltrates (SEIs, n = 13), and uveitis (n = 2). The lesions recurred in eight eyes (SPK and SEI 4 each) after a disease-free interval of 60.4 ± 40.6 days; there were 13 episodes of recurrence. Topical low potent corticosteroids (loteprednol/fluorometholone), and tacrolimus ointment 0.03% were used in 17 (80.9%) and 8 (38%) eyes, respectively, for a mean duration of 44.8 ± 31.6 and 226.8 ± 180.5 days, respectively. At follow-up, 172.3 ± 183.6 days, visual recovery was statistically significant in persistent eyes (BCVA 0.07 ± 0.07 logMAR; P < 0.00001) but, not in recurrent eyes (BCVA 0.16 ± 0.08 logMAR; P = 0.07). Five of 21 eyes were left with residual significant scar.Conclusion:The sequelae of microsporidial keratoconjunctivitis are not uncommon. Topical 0.03% tacrolimus ointment appeared to be an effective corticosteroid-sparing agent for the treatment of SEIs and prevention of recurrence.

A Narrative Review of Microsporidial Infections of the Cornea.

Microsporidia are a rare and commonly misdiagnosed cause of corneal infection, accounting for approximately 0.4% of cases of microbial keratitis in some populations. Ocular microsporidiosis most often presents as either microsporidial keratoconjunctivitis (MKC) or microsporidial stromal keratitis (MSK). Though these two clinical entities exhibit similar symptomology, they are distinguished from one another by the time course for disease progression, findings on slit-lamp examination, and response to medical therapy. This review summarizes the current literature on the etiology and clinical presentation of microsporidial infections of the cornea and highlights ongoing developments in available diagnostic modalities and treatment regimens.

Clinical Profile of Bilateral Microsporidial Keratoconjunctivitis in Healthy Individuals-A Case Series With Long-term Follow-up.

To describe bilateral microsporidial keratoconjunctivitis in healthy individuals with long-term follow-up. Six cases of smear-positive bilateral microsporidial keratoconjunctivitis were diagnosed and followed up during the study period August 2017 to January 2019. Associated risk factors, clinical features, coexistence with adenovirus, clinical course, and recurrence were studied. The mean age was 36.6 years (range: 10-65 years). The mean duration of symptoms was 13.6 days (range: 7-60 days). Predisposing risk factors were present in 4 of 6 cases. The best-corrected visual acuity at presentation was ≥20/30 in all eyes except in one. Typical microsporidial epithelial lesions were seen in only one case. Persistent lesions, clinically resembling Thygeson superficial punctate keratitis in both eyes, were observed in 3 cases. The lesions in 5 eyes resolved with topical lubricants, and the remaining 7 eyes were treated with topical steroids and tacrolimus 0.03%. Complete resolution was seen in 5 eyes at the end of 1 month, and superficial scarring at the last follow-up was seen in 5 eyes. The best-corrected visual acuity was ≤20/30 in 3 eyes at the last follow-up. The mean duration of follow-up was 7.3 months (range: 3-12 mo). Bilateral microsporidial keratoconjunctivitis in healthy patients has an atypical presentation with prolonged course. Microsporidia could be implicated as potential candidates in the etiopathogenesis of Thygeson superficial punctate keratitis.

Swimming Pool-Associated Vittaforma-Like Microsporidia Linked to Microsporidial Keratoconjunctivitis Outbreak, Taiwan.

We analyzed 2 batches of environmental samples after a microsporidial keratoconjunctivitis outbreak in Taiwan. Results indicated a transmission route from a parking lot to a foot washing pool to a swimming pool and suggested that accumulation of mud in the foot washing pool during the rainy season might be a risk factor.

Demographic and clinical profile of microspodial keratitis in North India: an underreported entity.

Ocular microsporidiosis was first described in immunocompromised subjects but recent reports have also shown cases in immunocompetent hosts. The database of existing clinical studies is very limited. The aim of present study was to analyse demographic profile, clinical features, microbiological profile, treatment and outcome of ocular microsporidiosis in northern India. The present study was carried out in the Department of Medical Parasitology, Advanced Eye Center, Postgraduate Institute of Medical Education and Research, and Bharat Vikas Parishad Charitable trust, Chandigarh. A total of 250 patients during year 2013-17 and suspected of microsporidial keratitis (either clinically or after exclusion of bacterial, viral or fungal agents). Corneal scraping were taken and subjected for various staining methods and PCR. 8 patients of microsporidial keratitis were confirmed, based on positivity by at least any two of the above mentioned techniques. None of the patients had history of contact lens wear or exposure to swimming pool. All these patients were systemically healthy and HIV serology was negative except one had history of diabetes mellitus. This study is a reminder to clinicians that when multifocal diffuse epithelial keratitis and culture-negative keratoconjunctivitis not responding to medical therapy, regardless of immune status are found in patients with symptoms suggesting an infectious keratitis, microsporidial keratoconjunctivitis should be included in the differential diagnosis.

Anterior Segment Optical Coherence Tomography Images in Microsporidial Keratoconjunctivitis.

To describe the findings of anterior segment optical coherence tomography (AS-OCT) in patients with microsporidial keratoconjunctivitis. The observational study included 13 eyes from 13 patients. Slit-lamp photography and AS-OCT were performed using the Swept source OCT before corneal scraping. All cases were positive for Gram-chromotrope (modified trichrome) staining for Microsporidia spp. Three significant AS-OCT findings were observed. First, hyperreflective dots were limited to the epithelial layers of the cornea, and second, there were no extensions into the stromal layer in all cases. Last, hyperreflective dots slightly raised above the epithelial surface were observed in most cases (12/13%, 92.3%). AS-OCT represents an alternative, noninvasive tool to diagnose microsporidial keratoconjunctivitis, especially if corneal scraping is not possible.

Outbreak of Microsporidial Keratoconjunctivitis Associated With Water Contamination in Swimming Pools in Taiwan

To report an outbreak of microsporidial keratoconjunctivitis resulting from a swimming pool in Taiwan. Retrospective case series. The records of 13 teenagers (15 eyes) contracting microsporidial keratoconjunctivitis after swimming in a local swimming pool were reviewed. Corneal scrapings were collected in all eyes at a tertiary referred hospital in June 2017. Gram stain, modified Kinyoun acid-fast stain, polymerase chain reaction (PCR), and gene analysis of the microsporidian 16S ribosomal RNA (rRNA) were examined in all 15 cases. Symptoms occurred 1-12days after the water contact. At presentation, all eyes showed nonpurulent conjunctivitis and small, plaque-like epithelial lesions peripherally (n= 6), centrally (n= 3), both peripherally and centrally (n= 5), or centrally with superficial punctate keratopathy (n= 1). During the follow-up period, 10 eyes developed central superficial punctate keratopathy (n= 6) or subepithelial haze or infiltrates, which were distributed centrally (n= 2) or peripherally (n= 3), following development of plaque-like epithelial lesions. The results of Gram stain and modified Kinyoun's acid-fast stain were confirmatory in 10 cases (67%). All 15 cases yielded positive PCR results and were all identified to be Vittaforma corneae. All followed-up eyes healed without sequelae using topical levofloxacin and betamethasone eye drops. Microsporidial keratoconjunctivitis can develop from contact with swimming pool water. The clinical course initially manifested as rapidly resolving conjunctivitis and peripheral plaque-like epithelial lesions, followed by paracentral or central plaque-like epithelial lesions, which evolved into subepithelial haze or infiltrates.

Microsporidial Keratoconjunctivitis in a Pet Bearded Dragon (Pogona vitticeps)

A 4-month-old female bearded dragon (Pogona vitticeps) was presented with unilateral conjunctivitis. The conjunctivitis was not responsive to topical antibiotic or anti-inflammatory therapy and continued to progress in severity. Conjunctival tissue was sampled and microsporidial conjunctivitis was diagnosed on histopathological evaluation of submitted samples. Medical therapy was initiated and included topical itraconazole, systemic itraconazole, and systemic fenbendazole. Serial serum chemistry panels and complete blood counts were monitored for potential side effects associated with the medications. Despite treatment, the conjunctivitis progressed and enucleation was performed. Histopathology on the enucleated globe confirmed the diagnosis of microsporidial keratoconjunctivitis. Systemic itraconazole was administered at 5mg/kg orally for approximately 3 months. No abnormalities were detected on hematologic diagnostic testing during the treatment period. A computed tomographic scan was performed to monitor for systemic lesions, but no abnormalities were detected. About 12 months after initial presentation, the bearded dragon is healthy and there are no overt signs of disease.

Clinical and demographic study of microsporidial keratoconjunctivitis in South India: a 3-year study (2013–2015)

AimTo study the demographic profile, clinical features, treatment outcome and ocular morbidity of smear-positive microsporidial keratoconjunctivitis.MethodsRetrospective case series of all patients with clinical features of microsporidial keratoconjunctivitis and who were...

In vivo confocal microscopic characteristics of microsporidial keratoconjunctivitis in immunocompetent adults

Background/aimsTo describe in vivo confocal microscopy (IVCM) features of microsporidial keratoconjunctivitis in immunocompetent adult patients.MethodsPatients suspected clinically to be suffering from microsporidial keratoconjunctivitis (ie, presence of unilateral follicular and/or papillary...

The Efficacy of Corneal Debridement in the Treatment of Microsporidial Keratoconjunctivitis: A Prospective Randomized Clinical Trial

To evaluate the efficacy of corneal debridement in the treatment of clinically diagnosed cases of microsporidial keratoconjunctivitis. Prospective, double-masked randomized clinical trial. Patients with clinical features such as multifocal, coarse, raised, punctate, round to oval epithelial lesions in the cornea in slit-lamp examination with mild to moderate conjunctival congestion, suggestive of microsporidial superficial keratoconjunctivitis, were included in the prospective study. All patients were randomized into 2 groups. Group 1 patients underwent debridement with the help of a sterile #15 blade on a Bard-Parker handle, whereas only conjunctival swabs were taken from Group 2 patients. All patients were treated with ocular lubricants. One hundred and twenty patients with clinical features suggestive of microsporidial superficial keratoconjunctivitis were included in the study. The mean age was 34.3 ± 13.6 years (Group 1) and 35.8 ± 16.2 years (Group 2) (P = .59). The mean duration of symptoms was 6.8 ± 3.9 days (Group 1) and 7.2 ± 4.6 days (Group 2) (P = .61). Baseline characteristics showed no difference between the 2 groups. The primary outcome was the time from the presentation to complete resolution (ie, absence of corneal lesions) of the clinical signs and symptoms. The secondary outcomes were final visual acuity and residual corneal side effects and/or scarring, if any. The mean resolution time of the corneal lesions was 5.7 ± 4.0 days (Group 1) and 5.9 ± 3.9 days (Group 2) (P = .83). There was no significant difference in final visual outcome in the 2 groups. No serious side effects were observed. Debridement does not have any significant advantage in terms of resolution of the corneal lesions and final visual outcome in cases of microsporidial keratoconjunctivitis.

Microsporidial Keratoconjunctivitis after Rugby Tournament, Singapore

We investigated an outbreak of 47 probable and 6 confirmed cases of microsporidial keratoconjunctivitis involving participants of an international rugby tournament in Singapore in April 2012.The mode of transmission was eye contact with soil. Vittaforma corneae was identified in 4 of 6 corneal scrapings and in 1 of 12 soil water samples.