Fungal keratitis
A fungal keratitis is an inflammation of the cornea that results from infection by a fungal organism. Keratomycosis is the fungal infection of the cornea, the anterior part of the eye which covers the pupil. Those experiencing these symptoms are typically advised to immediately visit the appropriate eyecare professional.
| Keratomycosis | |
|---|---|
| Specialty | Ophthalmology  |
Presentation
The symptoms of fungal keratitis are blurred vision, a red and painful eye that does not improve when contact lenses are removed, or on antibiotic treatment, increased sensitivity to light (photophobia), and excessive tearing or discharge. The symptoms are markedly less as compared to a similar bacterial ulcer. Signs: The eyelids and adnexa involved shows edema and redness, conjunctiva is chemosed. Ulcer may be present. It is a dry looking corneal ulcer with satellite lesions in the surrounding cornea. Usually associated with fungal ulcer is hypopyon, which is mostly white fluffy in appearance. Rarely, it may extend to the posterior segment to cause endophthalmitis in later stages, leading to the destruction of the eye. (Note: Fungal endophthalmitis is extremely rare)
Causes
Filamentous fungi
Yeasts
Fusarium spp. is most common then Aspergillus spp. and thirdly Dematitious fungi causing fungal keratitis in India.
Pathophysiology
The precipitating event for fungal keratitis is trauma with a vegetable / organic matter. A thorn injury, or in agriculture workers, trauma with a wheat plant while cutting the harvest is typical. This implants the fungus directly in the cornea. The fungus grows slowly in the cornea and proliferates to involve the anterior and posterior stromal layers. The fungus can break through the descemet's membrane and pass into the anterior chamber. The patient presents a few days or weeks later with fungal keratitis.
Diagnosis
The diagnosis is made by an ophthalmologist/optometrist correlating typical history, symptoms and signs. Many times it may be missed and misdiagnosed as bacterial ulcer. A definitive diagnosis is established only after a positive culture report (lactophenol cotton blue, calcoflour medium), typically taking a week, from the corneal scraping. Recent advances have been made in PCR ref 3./immunologic tests which can give a much quicker result.
Classification
Infectious keratitis can be bacterial, fungal, viral, or protozoal. Remarkable differences in presentation of the patient allows presumptive diagnosis by the eye care professional, helping in institution of appropriate anti-infective therapy.
Prevention
Prevention of trauma with vegetable / organic matter, particularly in agricultural workers while harvesting can reduce the incidence of fungal keratitis. Wearing of broad protective glasses with side shields is recommended for people at risk for such injuries.
Treatment
A presumptive diagnosis of fungal keratitis requires immediate empirical therapy. Natamycin ophthalmic suspension is the drug of choice for filamentous fungal infection. Fluconazole ophthalmic solution is recommended for Candida infection of the cornea. Amphotericin B eye drops may be required for non-responding cases, but can be quite toxic and requires expert pharmacist for preparation. Other medications have also been tried with moderate success. An updated Cochrane Review published in 2015 looking at the best treatment for fungal keratitis could not draw any conclusions as the studies included used different medications. [1] The review did find that "people receiving natamycin were less likely to develop a hole in their cornea and need a transplant."
Consult your eye care professional in any case as they will have the best treatment.
Prognosis
The infection typically takes a long time to heal, since the fungus itself is slow growing. Corneal perforation can occur in patients with untreated or partially treated infectious keratitis and requires surgical intervention in the form of corneal transplantation.
Epidemiology
This disease is quite common in the tropics and with large agrarian population. India has a high number of cases with fungal keratitis, but poor reporting system prevents accurate data collection. Florida in US regularly reports cases of fungal keratitis, with Aspergillus and Fusarium spp. as the most common causes.
Social impact
The loss of vision with fungal keratitis can be quite disabling in terms of economic impact and social consequences. Many people come with fungal keratitis in the only eye and thus become blind due to the disease. The lack of education and proper eye protection in such cases is evidently responsible for their plight.
Notable cases
Recently, one particular product, ReNu with MoistureLoc brand of soft contact lens solutions made headlines regarding a report from the United States Centers for Disease Control and Prevention suggesting an increased incidence of a specific type of fungal keratitis (Fusarium keratitis) in people using Bausch & Lomb products.[2] Bausch & Lomb subsequently suspended, then recalled, shipments of one particular product, ReNu with MoistureLoc.[3]
See also
References
- FlorCruz, Nilo Vincent; Evans, Jennifer R (2015-04-09). Cochrane Eyes and Vision Group (ed.). "Medical interventions for fungal keratitis". Cochrane Database of Systematic Reviews (4): CD004241. doi:10.1002/14651858.CD004241.pub4. PMID 25855311.
- "Fusarium Keratitis --- Multiple States, 2006." Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report. April 10, 2006 / 55(Dispatch);1-2.
- "Bausch & Lomb News". Archived 2006-04-12 at the Wayback Machine Bausch & Lomb. Retrieved. June 2, 2006.
3. Use of PCR targeting of internal transcribed spacer regions and single-stranded conformation polymorphism analysis of sequence variation in different regions of rRNA genes in fungi for rapid diagnosis of mycotic keratitis. Manish Kumar and PK Shukla (2005). J. Clin. Microbiol. 43 (2), 662-668