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Fungal Keratitis: the Challenges of Diagnosis, Treatment, and Management

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Fungal Keratitis: the Challenges of Diagnosis, Treatment, and Management Fungal Keratitis: The Challenges of Diagnosis, Treatment, and Management Justin Alexander Schweitzer OD, FAAO Abstract Fungal infections are commonly resistant to treatment, penetrate deep into the cornea, take days to culture and extended periods of time to heal. This case report discusses the management of fungal keratitis. I. Case History a. Patient SB, a Caucasian 29 year old male was referred to our clinic for a corneal ulcer OD. b. Chief Complaint: Decreased distance VA and significant pain OD. No problems or complaints OS. c. Past Ocular History: SB scratched his OD two weeks before presenting to our clinic while power washing a hog confinement. He does not wear contact lenses only spectacles. d. Past Medical History: Unremarkable e. Medications – Referring OD started gatifloxacin q1h OD and loteprednol 0.2% 2 x a day OD f. Family Medical History: Diabetes g. Allergies: amoxicillin II. Pertinent findings a. Distance Visual Acuity w/ specs: 20/400 OD and 20/20 OS. Pinhole acuity OD – 20/100 b. No manifest refraction performed due to the intense pain and photophobia experienced by the patient. c. Pupils were equally round and reactive to light, no afferent pupil defect was noted OU. Confrontation fields were not tested. Extraocular muscles were unrestricted in all gazes. d. IOP: 14mmHG OD and 10 mmHG OS e. Anterior Segment OD – 4 x 4 mm central, mildly opaque corneal ulcer. No satellite lesions present, but the edges appeared “feathery” (Image available). 2+ conjunctival injection. AC was deep and quiet. Lens was clear. Evaluation OS was normal. f. Undilated Fundus Examination – difficult due to intense pain and photophobia i. C/D Ratio: OD 0.20/0.20 OU with normal neuroretinal rims. ii. A/V ratio: 2/3 iii. Macula: Flat and intact III. Differential Diagnosis a. Primary/Leading i. Bacterial Corneal Ulcer OD b. Others i. Fungal Corneal Ulcer ii. Herpes Simplex Virus Keratitis iii. Acanthamoeba Keratitis IV. Diagnosis and discussion a. Diagnosis i. Culture of ulcer was obtained – sabouraud, chocolate, blood agar, and thioacrylate broth medium. ii. Initial Diagnosis – Bacterial Corneal Ulcer/Infectious Bacterial Keratitis OD V. Treatment, management a. Treatment and response to treatment i. The decision was made to start fortified vancomycin and tobramycin q1h OD during the day and q2h OD throughout the night until culture results were obtained. All other drops were stopped. Follow-up in 48 hours. ii. Follow-up #1 -SB states that he is starting to feel better and could actually open his eye a little today. SB is applying one drop of fortified vancomycin and tobramycin every two hours OD during the day and during the night. Uncorrected VA – CF @ 3ft. A stable 4 x 4 mm central, mildly opaque corneal ulcer. It appeared slightly improved as the edges of the ulcer appeared less “feathery”. The conjunctiva had 2+ injection OD. His IOP was 14 OD. SB was instructed to continue the vancomycin and tobramycin every hour and the importance was stressed to him of using it every hour. He was asked to return to our clinic two days later for re-evaluation. iii. Follow-up #2 – SB states that he is starting to see a little better. SB is applying one drop of fortified vancomycin and tobramycin every one hour OD during the day and every two hours during the night. His uncorrected visual acuity OD is 20/400 with no improvement with pinhole. Slit lamp examination OD showed a stable 4 x 4 mm central, mildly opaque corneal ulcer. No improvement was noted from two days earlier. The conjunctiva had 2+ injection OD. The remainder of the slit lamp examination was normal OD. His IOP was 9 OD. A positive growth of Fusarium was noted on one of the bacterial cultures. SB was instructed to stop the vancomycin and tobramycin. He was prescribed natamycin 5% and instructed to apply one drop every hour OD during the day. He was asked to return to our clinic three to five days later for re-evaluation. iv. SB states things are going a lot better. He states his vision is better and he is not as light sensitive. SB is applying one drop of natamycin 5% every one hour OD during the day. His corrected visual acuity OD is 20/40. Slit lamp examination OD showed a 4 x 4 mm central, mildly opaque corneal scar. The tissue appeared re-epithelized. The conjunctiva had 3+ injection OD. The remainder of the slit lamp examination was normal OD. His IOP was 11 OD. SB was instructed to taper the natamycin 5% to one drop every two hours OD. A prescription for difluprednate 0.05% was given and SB was instructed to apply one drop one time a day only OD. He was asked to return to our clinic in one week for re-evaluation. v. SB states his vision is better and things continue to improve. SB is applying one drop of natamycin 5% every two hours OD during the day and one drop of difluprednate 0.05% one time a day OD. His corrected visual acuity OD is 20/25. Slit lamp examination OD shows a stable 4 x 4 mm central, mildly opaque corneal scar. The conjunctiva has 1+ injection OD. The remainder of the slit lamp examination was normal OD. His IOP was 13 OD. SB was instructed to taper the natamycin 5% to one drop four times a day OD. He was instructed to continue the difluprednate 0.05% one drop one time a day OD. SB was asked to return to our clinic in one week for re-evaluation. vi. SB states his vision is a little blurry, but the eye is comfortable. SB is applying one drop of natamycin 5% four times a day OD and one drop of difluprednate 0.05% one time a day OD. His corrected visual acuity OD is 20/40. Slit lamp examination OD shows a stable 4 x 4 mm central, mildly opaque corneal scar. The conjunctiva has no injection OD. The remainder of the slit lamp examination was normal OD. His IOP was 14 OD. SB was instructed to taper the natamycin 5% to one drop two times a day OD. He was instructed to continue the difluprednate 0.05% one drop one time a day OD. SB was asked to return to our clinic in one week for re-evaluation. vii. SB states his vision is great and the eye is comfortable. SB is applying one drop of natamycin 5% two times a day OD and one drop of difluprednate 0.05% one time a day OD. His corrected visual acuity OD is 20/25. Slit lamp examination OD shows a stable 4 x 4 mm central, mildly opaque corneal scar. The conjunctiva has no injection OD. The remainder of the slit lamp examination was normal OD. His IOP was 15 OD. SB is instructed to stop the natamycin 5% and the difluprednate 0.05%. SB was asked to return to our clinic in one week for re-evaluation. SB was lost to follow-up after this visit. viii. Discussion 1. In order to make a diagnosis of fungal keratitis it is important to understand the risk factors associated with it and how it presents. The location of the eye care provider’s clinic or where a patient has traveled recently are significant risk factors.1,2 It is much more common to see fungal keratitis in hot and humid areas. Three other significant risk factors are trauma involving vegetative or agricultural material, contact lens use or abuse, and immunocompromised individuals.1,2 Fungal infections take time to get worse. The condition typically will build for weeks before becoming debilitating to the patient.3 In comparison bacterial infections will present as normal one day, and the next day the eye is painful with significant inflammation.4 It is common to see satellite lesions with fungal infections, which surround the main lesion. Fungal ulcers will usually go deeper into the cornea than bacteria, and also have feathery borders compared to more distinct borders seen with bacterial infections.3,4 Finally, another feature of fungal infections is that the eye can be relatively quiet compared to bacterial keratitis.3,4 Culturing or a biopsy are crucial to make a definitive diagnosis of fungal keratitis. Filamentous fungi are treated with natamycin every one hour. Previously, filamentous fungal infections of the cornea were treated with voriconazole, until the results of the Mycotic Ulcer Treatment Trial (MUTT).5 In this trial natamycin outperformed voriconazole. Patients on natamycin in the MUTT were less likely to suffer a perforation or need a therapeutic penetrating keratoplasty compared to patients on voriconazole.5 Patients should be followed daily or every other day while hourly treatment is being initiated. Once the ulcer responds to treatment and begins to improve, less frequent follow-up is possible, and a tapering schedule is begun. Patients should be educated that treatment could last many months. 1. Rosa Jr RH, Miller D, Alfonso EC. The Changing Spectrum of Fungal Keratitis in South Florida. Ophthalmology 1994; 101(6): 1005-1013. 2. Jurkunas U, Behlau I, Colby K. Fungal Keratitis: Changing Pathogens and Risk Factors. Cornea 2009; 28 (6): 638-643. 3. Keay LJ, Gower EW, Iovieno A, Oechsler RA, Alfonso EC, et al. Clincial and Microbiological Characteristics of Fungal Keratitis in the United States, 2001-2007: A Multicenter Study. Ophthalmology 2011; 118 (5): 920-926. 4. Bourcier T, Thomas F, Borderie V, Chaumeil C, Laroche L. Bacterial Keratitis: Predisposing Factors, Clinical and Microbiological Review of 300 cases. Br J Ophthalmol 2003; 87: 834-838. 5. Prajna NV, Krishnan T, Mascarenhas J, et al.
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