Natamycin Eye Drops Research Articles

Severe fusarium oxysporum keratomycosis: About 2 Cases

Fungal keratitis is a destructive ocular infection, representing a serious diagnostic and therapeutic problem, difficult to treat and with poor results. It can cause irreversible damage. Keratomycoses are rare and may be under-diagnosed. Direct microscopic examination and culture are essential for early specific diagnosis and must be taken into consideration to establish the most effective treatment and avoid serious complications. The pathogenesis of this infection is based on three factors: colonization, tissue damage and immunosuppression. We report 2 cases of Fusarium oxysporum keratomycosis treated with amphotericin B. The diagnosis of corneal abscess was made after ophthalmological examination in 2 adult males with no previous ophthalmological history, referred to the Omar Drissi hospital in Fez for decreased visual acuity, photophobia, redness and intense pain in the right/left eye. Corneal scrapings were taken for microbiological analysis, and after initial mycological results, local and systemic antifungal treatment was initiated with amphotericin B and natamycin eye drops. The evolution was marked by a corneal perforation with a tenon patch graft for the first patient, and healing for the 2nd

Intrastromal and intracameral voriconazole combination: An adjuvant therapy in intractable mycotic keratitis

: To study role of intrastromal and intracameral voriconazole combination in recalcitrant fungal Keratitis.: 20 cases of recalcitrant fungal keratitis involving >50% stromal thickness and not showing good response to oral fluconazole, topical natamycin (5%) and topical voriconazole (1%) eye drops after 4 weeks of treatment were included in the study after taking informed written consent. Patients with impending or frank perforation, scleral involvement and endophthalmitis were excluded from the study. 30 min before the procedure, patient was given Tab acetazolamide 250mg stat to lower the intraocular pressure (IOP). Then under all aseptic conditions, 50 microgram/0.1 ml dose of intrastromal and intracameral voriconazole was given with 30G needle. Cases were examined daily for 1 week and then every week for 4 weeks for monitoring progression of fungal keratitis. Out of 20 cases, 18 (90%) patients showed significant improvement after 4 weeks. Depending on the response after 1 week, patients were planned for repeat injection and only 1 patient required >3 injections in whom Lasiodiplodia theobromae was the causative organism. Only 1 patient got worsened and was ultimately managed with therapeutic keratoplasty. Intrastromal and intracameral voriconazole combination is an easy procedure with short learning curve which is highly efficacious and cost effective in recalcitrant fungal keratitis.

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.

CANDIDA PANOPHTHALMITIS WITH IATROGENIC HYPERADRENOCORTICISM IN TWO DOGS

Two adult poodles were referred for severe corneal ulcers in both eyes (oculi uterque [OU]) for 1.5 months, and swollen eyelids for approximately 1 week. Ophthalmic examination revealed diffuse corneal edema with grayish deposit and ulcer, uveitis, glaucoma, grayish deposit and necrosis on the third eyelid and conjunctiva, eyelids necrosis, eyelid-eyeball adhesions, and blindness. Cytological examination of the conjunctiva and cornea revealed neutrophilic inflammation, and a bacterial culture revealed Staphylococcus aureus. An adrenocorticotropic hormone stimulation test was performed, strongly indicating iatrogenic hyperadrenocorticism. No improvement was observed after 2 weeks of antibiotic treatment. Fungal cultures from the cornea and conjunctiva were positive for Candida spp. Specific antifungal treatment included topical 5% natamycin eye drops (OU six times daily) and oral itraconazole (5[Formula: see text]mg/kg q12[Formula: see text]h). The grayish deposits of the conjunctiva and cornea were sloughed off, thus facilitating the healing of corneal and eyelids ulcers, over the next 3–4 weeks. Phthisis bulbi and eyelid-eyeball adhesions developed in both dogs after 6 months of follow-up. Based on the fungal isolation by culture, clinical signs, and response to antifungal treatment, Candida spp. panophthalmitis was diagnosed. Fungi should be considered a potential organism in panophthalmitis, especially with a medical history of steroids and antibiotic use. This case report demonstrates the grayish deposits of the cornea, conjunctiva, and third eyelid as possible characteristics of Candida infection in the dogs. To our knowledge, this is the first report of Candida panophthalmitis with iatrogenic hyperadrenocorticism in dogs.

Drug-loaded mesoporous carbon with sustained drug release capacity and enhanced antifungal activity to treat fungal keratitis.

Fungal keratitis is a severe infectious corneal disease with a high rate of incidence and blindness. Since traditional treatments natamycin (NATA) eye drops, exhibit poor dissolution and bioavailability, and the efficacy of current therapeutic approaches remains limited. In this study, we innovatively utilized mesoporous carbon (Meso-C) and microporous carbon (Micro-C) as nanocarriers loaded with the antifungal drug NATA and silver nanoparticles (Ag-NPs). Porous carbon loaded with NATA and Ag-NPs has not previously been studied in fungal keratitis. Due to the mesoporous structure, high surface area and larger pore volume of Meso-C, it displayed greater superiority in sustained drug release and drug dispersity than Micro-C. Moreover, Meso-C could adsorb inflammatory cytokines during fungal infection. In vitro, Meso-C/NATA/Ag showed excellent antifungal effects. In vivo, compared with pure NATA treatment, Meso-C/NATA/Ag exhibited significantly improved therapeutic effects and reduced dosing frequency when treating fungal keratitis. Our study is the first to report the sustained drug release and improved drug dispersity of Meso-C/NATA and demonstrates that NATA and Ag-NPs-loaded Meso-C has therapeutic effects against fungal keratitis.

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.

Successful medical management of bilateral microsporidial stromal keratitis

An 81-year-old gentleman with a vague history of dust falling into the eyes presented with a white lesion in the left eye for 5 months. Both eyes showed two foci of central dense stromal infiltrates with keratic precipitates. Suspecting herpes simplex virus (HSV) keratouveitis, topical steroids, and antiviral eye ointment were started. A month later, he developed unilateral microsporidial keratoconjunctivitis with persistent bilateral deep stromal keratitis. The corneal scrapings revealed microsporidial spores on 10% Potassium hydroxide (KOH)with Calcofluor White Stain. Topical 1% voriconazole eye drops for 4 months in the right eye, a combination of 1% voriconazole and Natamycin eye drops for 9 months in the left eye and oral albendazole 400 mg twice daily for 3 weeks resulted in complete resolution. There were no recurrences over 1 year. We present a literature review of the medical management of microsporidial stromal keratitis highlighting our case with bilateral disease successfully managed medically with antifungal therapy.

The management of microbial keratitis within Uganda’s primary health system: a situational analysis

Background: Microbial keratitis (MK) frequently leads to sight-loss, especially when the infection is severe and/or appropriate treatment is delayed. The primary health system as an entry point plays a central role in facilitating and directing patient access to appropriate care. The purpose of this study was to describe the capacity of primary health centres in Uganda in managing MK. Methods: We carried out a rigorous assessment of primary health centres and mid-cadre training schools in South Western Uganda. Through interviews, checklists and a picture quiz, we assessed capacity and knowledge of MK management. In addition, we interviewed the heads of all the mid-cadre training schools to determine the level of eye health training provided in their curricula. Results: In total, 163 health facilities and 16 training schools were enrolled. Of the health facilities, only 6% had an Ophthalmic Clinical Officer. Only 12% of the health workers could make a diagnosis of MK based on the clinical signs in the picture quiz. Although 35% of the facilities had a microscope, none reported doing corneal scraping. None of the facilities had a stock of the recommended first line treatment options for MK (ciprofloxacin and natamycin eye drops). Among the training schools, 15/16 had an eye health component in the curriculum. However, the majority (56%) of tutors had no formal expertise in eye health. In 14/16 schools, students spent an average of two weeks in an eye unit. Conclusions: Knowledge among health workers and capacity of health facilities in diagnosis and management of MK was low. Training for eye health within mid-cadre training schools was inadequate. More is needed to close these gaps in training and capacity.

MSCs helped reduce scarring in the cornea after fungal infection when combined with anti-fungal treatment

BackgroundFungal Keratitis (FK) is an infective keratopathy with extremely high blindness rate. The damaging effect of this disease is not only the destruction of corneal tissue during fungal infection, but also the cornea scar formed during the healing period after infection control, which can also seriously affect a patient’s vision. The purpose of the study was to observe the effect of umbilical cord mesenchymal stem cells (uMSCs) on corneal scar formation in FK.MethodsThe FK mouse model was made according to a previously reported method. Natamycin eye drops were used for antifungal treatment 24 h after modeling. There are four groups involved in the study, including control group, FK group, vehicleinj FK group and uMSCsinj FK group. Mice in uMSCsinj FK group received repeated subconjunctival injections of uMSCs for 3 times at the 1d, 4d and 7d after FK modeling. At 14d, 21d and 28d after trauma, clinical observation, histological examination, second harmonic generation and molecular assays were performed.ResultsThe uMSCs topical administration reduced corneal scar formation area and corneal opacity, accompanying with decreased corneal thickness and inflammatory cell infiltration, following down-regulated fibrotic-related factors α-SMA, TGFβ1, CTGF, and COLI and finally inhibited phosphorylation of TGFβ1/Smad2 signaling pathway during FK corneal fibrosis.ConclusionThe results confirmed that uMSCs can improve corneal opacity during the scar formation stage of FK, and exert anti-inflammatory and anti-fibrotic effects.

The management of microbial keratitis within Uganda's primary health system: a situational analysis.

Background: Microbial keratitis (MK) frequently leads to sight-loss, especially when the infection is severe and/or appropriate treatment is delayed. The primary health system as an entry point plays a central role in facilitating and directing patient access to appropriate care. The purpose of this study was to describe the capacity of primary health centres in Uganda in managing MK. Methods: We carried out a rigorous assessment of primary health centres and mid-cadre training schools in South Western Uganda. Through interviews, checklists and a picture quiz, we assessed capacity and knowledge of MK management. In addition, we interviewed the heads of all the mid-cadre training schools to determine the level of eye health training provided in their curricula. Results: In total, 163 health facilities and 16 training schools were enrolled. Of the health facilities, only 6% had an Ophthalmic Clinical Officer. Only 12% of the health workers could make a diagnosis of MK based on the clinical signs in the picture quiz. Although 35% of the facilities had a microscope, none reported doing corneal scraping. None of the facilities had a stock of the recommended first line treatment options for MK (ciprofloxacin and natamycin eye drops). Among the training schools, 15/16 had an eye health component in the curriculum. However, the majority (56%) of tutors had no formal expertise in eye health. In 14/16 schools, students spent an average of two weeks in an eye unit. Conclusions: Knowledge among health workers and capacity of health facilities in diagnosis and management of MK was low. Training for eye health within mid-cadre training schools was inadequate. More is needed to close these gaps in training and capacity.

Role of intrastromal voriconazole in recalcitrant fungal keratitis

Objectives: To study role of intrastromal voriconazole in recalcitrant fungal Keratitis.Material and Methods: 30 cases of fungal keratitis who were having >50% stromal thickness involvement and not showing good response to topical Natamycin (5%) and topical Voriconazole (1%) eye drops were included in the study. Cases with impending or frank perforation, involvement of sclera or endophthalmitis were excluded from the study. 50 microgram/0.1 ml of Voriconazole was injected with a 30G needle in midstoma, divided equally in all four quadrants. 1% voriconazole eye drops were also continued. Cases were examined daily for 1 week and then every week for 4 weeks.Results: Out of 30 patients, 24 patients (80%) showed significant improvement after 4 week, 3 patients (10%) did not show any improvement and 3 patients (10%) got worsened and ultimately managed with therapeutic keratoplasty.Conclusion: Intrastromal voriconazole is highly efficacious in recalcitrant fungal keratitis. It is just an OPD procedure. It may not only save the eye but less number of patients will require therapeutic keratoplasty.

Ocular manifestations and management of Fusarium and Sarocladium infections

Since 2017, the nomenclature of Fusarium, Acremonium and Sarocladium species have changed, as these morphologically homogeneous, but phylogenetically heterogeneous species and species complexes may be differentiated using MALDI-TOF MS examination, analyzing nucleotic sequences. This resulted in taxonomical changes. We summarize the clinical course, diagnostic and therapeutic options of keratitis caused by Fusarium and Sarocladium. The challenge of Fusarium and Sarocladium keratitis management for an ophthalmologist lies in delayed diagnosis and therapy, fulminant progression and penetration of the Descemet's membrane, restricted availability, poor penetration of antifungal agents and therapy resistance. The diagnosis is based on the clinical history of corneal trauma or contact lens wear, PCR and MALDI-TOF MS, confocal microscopic examination, microbiological culture and light-microscopic analysis of corneal scrapings. As primary conservative treatment, 5% natamycin eye drops have to be used and with results of an antimycogram, topical 1% voriconazole or 0.15-0.25% amphotericin B, in some cases 0.02% polyhexamethylene-biguanide (PHMB) may be applied. Fusarium keratitis may benefit from additional 2 × 200 mg oral voriconazole treatment, daily. In therapy resistant cases, early, large diameter penetrating keratoplasty (PKP) has to be performed, with complete removal of the infected area. With late diagnosis, delayed specific treatment and surgery, mycotic hyphae may penetrate the Descemet's membrane, leading to the loss of vision and enucleation in about every fourth patient. In our paper, we also present the heterogeneous clinical history of five Fusarium and Sarocladium keratitis cases. Orv Hetil. 2019; 160(1): 2-11.

Clinical observation on intracorneal injection of different anti-fungal drugs for the treatment of fungal keratitis caused by injury due to chestnut

Objective To observe the clinical efficacy of injection of different anti-fungal drugs in corneal stroma for the treatment of fungal keratitis caused by injury due to chestnut stab. Methods Eighty-three eyes of 83 cases of fungal keratitis caused by chestnut were randomly divided into three groups. The etiological results of all cases were obtained by fungal culture. After corneal debridement, patients in group A, group B and group C received the injection of fluconazole, amphotericin B and voriconazole in corneal stroma respectively on the basis of using 5% natamycin eye drops. The effect of the treatments for the three groups were observed. Results The first pathogenic bacteria was the Alternaria of the pathogen accounting for 34.9% (29 cases), followed by Fusarium 30.1% (25 cases) and Aspergillus 15.7% (13 cases). The cure rates of three groups were 70.3% (19/27), 76% (18/25) and 90.3% (28/31) respectively. The average cure rate of group C was higher than that of group A and B, and the differences were statistically significant (χ2=5.349, 4.895; P=0.021, 0.027). There was no statistically significant difference in the cure rate between group A and B (χ2=0.027, P=0.869). The cure time of group C was (22.48±8.36)d which was shorter than that of group A (27.40±3.97)d and group B (28.76±5.12)d and the differences were statistically significant (t=2.544, 3.006; P=0.014, 0.004). There was no statistically significant difference in the cure time between group A and B (t=1.069, P=0.290). Two cases in group B suffered eye irritation symptoms, and the symptom disappeared after the use of Diclofenac Sodium eye drops for two days. No adverse reactions during the treatment occurred in the remaining cases. All cases were followed up for 1-3 months and no puncture tract scar formed or no recurrent case happened. Conclusion The main pathogenic bacteria of fungal keratitis by chestnut stab are Alternaria and Fusarium. The injection of fluconazole, amphotericin B and voriconazole respectively in corneal stroma can bring better curative effect, especially the voriconazole and for severe cases the curative effect of voriconazole is better than that of fluconazole and amphotericin B. Key words: Keratitis, fungal; Chestnut stab; Etiological examination; Antifungal drugs; Injection, in corneal stroma

Study of Pathogens of Fungal Keratitis and the Sensitivity of Pathogenic Fungi to Therapeutic Agents with the Disk Diffusion Method

Purpose/aim of the study: To identify the causative fungi of fungal keratitis, test their susceptibility to antifungal agents with the disk diffusion method and study the relationship between the organisms, the inhibition zones and the clinical outcomes.Materials and methods: 535 patients with fungal keratitis in one eye were included in this study. Pathogenic fungi were isolated by corneal scraping, identified by fungal cultivation and subjected to drug sensitivity tests conducted with the disk diffusion method. The patients were treated initially with voriconazole, terbinafine and natamycin eye drops for one week. Further treatment continued using the most effective drug according to the drug sensitivity results. The patients were followed up every week until three months after cured. The inhibition zones of fungi cultured with voriconazole, terbinafine and natamycin were compared. The relationship between inhibition zones and organism, organism and treatment results measure, and each treatment results measure and inhibition zones were evaluated.Results: Of 535 patients, 53.84%, 19.25% and 26.91% were infected with Aspergillus, Fusarium and other fungi, respectively. Keratitis patients infected with Aspergillus keratitis had the worst outcome. The size of the inhibition zones of Aspergillus spp., Fusarium spp. and other fungal genera differed significantly in response to voriconazole, terbinafine and natamycin. The inhibition zone associated with natamycin correlated significantly with the clinical outcome of fungal keratitis (OR = 0.925), but no other such correlations were found for the other drugs tested.Conclusions: Aspergillus and Fusarium were the predominant pathogenic genera causing fungal keratitis in our patients. Among the causative fungi, infections due to Aspergillus spp. were associated with the worst outcomes. The inhibition zones of fungal isolates in response to natamycin significantly correlated with the treatment outcomes of keratitis. Specifically, the smaller the natamycin inhibition zone, the lower the probability that the fungal keratitis had been eliminated.

Evaluation of corneal collagen cross-linking as an additional therapy in mycotic keratitis.

To report the treatment outcomes of mycotic keratitis with collagen cross-linking. Retrospective study. Patients with smear-positive moderate mycotic keratitis. A retrospective case-file analysis was performed to identify cases of moderate mycotic keratitis treated with and without additional collagen cross-linking, in addition to intensive topical antifungal therapy. Patients in which collagen cross-linking was performed on the day of presentation (group 1) were compared with patients who received medical treatment alone in the form of 5% natamycin eye drops (group 2). The primary outcome measure was the time taken for resolution of infection. Overall, 41 cases were included for analysis (group 1, 20 cases; group 2, 21 cases). Mean age of the patients was comparable in both groups (46.5 ± 17.01 vs. 41.2 ± 20.7 years; P = 0.36). Average infiltrate size was 16.35 ± 6.8 mm(2) in group 1 and 17.09 ± 7.4 mm(2) in group 2 (P = 0.83). Overall, Aspergillus was the most commonly isolated organism (n = 4 group 1; n = 6 group 2). Resolution of infection was observed in 18 cases (90%) in group 1 and 18 (85.71%) cases in group 2. The average healing time was 30.85 ± 26.6 days in group 1, while it was 31.28 ± 19.97 days in group 2 (P = 0.94). Final best-corrected visual acuity in group 1 was 1.13 ± 0.55 and 1.25 ± 0.46 in group 2 (P = 0.46). A tectonic keratoplasty was performed in two cases in group 1 and three cases in group 2 (P = 1.00). In our study, additional collagen cross-linking treatment did not have any advantage over medical management in cases with moderate mycotic keratitis.

Unusual Pigmented Fungal Keratitis by Fonsecaea Copper Pennies

A 35 year male presented with wooden sti ck injury and corneal infi ltrates. On KOH wet mount, light brown coloured septate round shaped structures – “scleroti c bodies” were visible. Such bodies also known as Copper Pennies are characteristi cally found in pigmented fungus Fonsecaea species. The pati ent was put on Natamycin eye drops (1%), however he worsened on treatment. The pati ent was started on oral and topical Voriconazole (1%) and responded favorably. The infi ltrates healed and no recurrences were seen at 12 week follow up. We conclude that unusual pigmented fungus may be resistant to conventi onal treatment however may respond to voriconazole.

The treatment of traumatic fungal keratitis with natamycin eye drops

Objective To observe clinical effects and safeness of 5％ domestic Natamycin eye drops for the treatment of traumatic fungal keratitis.Methods From July 2013 to November 2013,thirty-seven eyes of 37cases of fungal keratitis diagnosed by corneal smear examination were treated by local debridement,iodine cauterization,and application of 5％ natamycin eye drops.The therapeutic effect was observed.Results Of thirty-seven cases,30 cases were cured,7 cases were improved.Conclusion Combined with local debridement and iodine cauterization,the 5 ％ domestic Natamycin eye drop is safe and effective for mild to moderate traumatic fungal keratitis. Key words: Natamycin ; Keratitis, fungal ; Cauterization, Iodine tincture

A Case ofPhoma glomerataKeratitis Occurred in Recurrent Herpes Simplex Keratitis Cicatrix

Purpose: To report a case of Phoma glomerata keratitis occurring in recurrent herpes simplex keratitis cicatrix. Case summary: A 63-year-old male patient was admitted to our hospital with complaints of abrupt visual deterioration and ocular pain in his left eye. He was treated for recurrent herpes simplex keratitis in the same eye 12 years prior. Because central desmatocele was observed as a result of advanced corneal stromal melting, Gram staining, Potassium Hydroxide (KOH) mount, and culture were performed in corneal scrape specimens. On microbiological evaluation, a Phoma species was detected and Phoma glomerata was diagnosed using DNA sequencing method. Two consecutive amniotic membrane transplantations were performed with topical antifungal agents. The lesion was not improved when using topical amphotericin B and natamycin eyedrops, thus fluconazole eyedrops were used additionally. The corneal infection was resolved with central thick opacification. Conclusions: In the present case, herpetic keratitis was the main underlying causative factor because the patient had no past history of trauma. When diverse appearances of keratitis occur in herpes simplex keratitis patients, clinicians need to consider the concurrence of fungal infection, especially Phoma glomerata, a rare fungal organism. J Korean Ophthalmol Soc 2014;55(8):1229-1232

Kératomycose grave à Fusarium solani induite par un corps étranger tellurique : à propos d’un cas au Sahara marocain

We report a case of severe keratitis due to Fusarium solani in a young man in the Sahara in Morocco where the climate is arid. This patient reported had a grain of sand in his right eye for a week after a sandstorm. On admission he had a corneal abscess. Despite rapid diagnosis and initiation of treatment with available antifungal drugs: amphotericinB and natamycin eye drops, the prognosis worsened and led to the enucleation of the right eye. Faced with a suspected eye infection after a microtrauma caused by grains of sand carried by a sandstorm, it is important to take biological samples to search for fungal infections among other. It is also important to have new triazole antifungal drugs available to treat ocular mycosis rapidly and effectively.

Role of voriconazole in combined acanthamoeba and fungal corneal ulcer

We report a case of a 21 year old male who presented with smear-proven fungal corneal ulcer in left eye, refractory to treatment with topical natamycin. Corneal smears and culture were taken along with anterior chamber tap for microbiological investigations and intracameral 1% voriconazole was injected followed by institution of oral as well as topical voriconazole drops. Corneal and aqueous smear as well as culture confirmed the presence of acanthamoeba. The keratitis responded favourably to voriconazole therapy which was instituted along with topical trophicidal drugs and anterior chamber became quiet by 7th day. The patient was slowly tapered from voriconazole and was off the drug by 6 months. At one year follow up, he continues to remain asymptomatic. The possibility exists that the fungal organisms had either partially or completely responded to natamycin eye drops and voriconazole therapy further inhibited their growth along with being highly efficacious in suppressing acanthamoeba trophozoites. Voriconazole may be specifically instrumental in corneal ulcers with coinfection of acanthamoeba and fungal organisms and preventing recrudescence of both. Normal saline wet mount and 10% KOH mount of paracentesis sample for suspicious cases of refractory corneal ulcers to specifically look for trophozoites in order to institute timely treatment are recommended.