Archana Khetan

Epidemiological profile of fungal keratitis in urban population of West Bengal, India

Background Corneal diseases are one of the major causes of visual loss and blindness, second only to cataract. Amongst corneal diseases, microbial keratitis is a major blinding disease. In some countries, fungal keratitis accounts for almost 50% of patients with culture-proven microbial keratitis. Aim This study was conducted to determine the epidemiological characteristics of fungal keratitis in an urban population of West Bengal and identify the specific pathogenic organisms. Methods The charts of patients with microbial keratitis who attended the Cornea Services of Priyamvada Birla Aravind Eye Hospital from January to December 2008 were retrospectively reviewed. Records of patients with 10% KOH mount and culture positive fungal keratitis were analyzed for epidemiological features, laboratory findings and treatment outcomes. Results Of the 289 patients of microbial keratitis included in the study, 110 patients (38.06%) were diagnosed with fungal keratitis (10% KOH mount positive). Of the 110 patients, 74 (67.27%) fitted the study inclusion criteria (10% KOH mount and culture positive). Forty five of 74 patients (60.81%) in the study group were in the older age group (>50 years). Ocular trauma in 35 cases (47.29%) was identified as a high risk factor and vegetative injuries in 17 cases (22.97%) were identified as a significant cause for fungal keratitis. Maximum organism source was from corneal scrapings in 41 cases (55%). The predominant fungal species isolated was Aspergillus sp (55.40%) followed by Candida albicans 14 cases (18.91%) and Fusarium sp. in 8 cases (10.81%). Agricultural activity related ocular trauma was the principal cause of mycotic keratitis and males were more commonly affected. Thirty of 74 cases (40.55%) of the culture positive patients healed with corneal scar formation with medical treatment whereas 44 cases (59.45%) required therapeutic keratoplasty. Conclusion Fungal keratitis is an important cause of microbial keratitis with injury to the cornea being a leading predisposing factor. Although Aspergillus sp. was implicated in most of the patients in our study population, Candida sp. were found in higher numbers than previously reported. Keratitis caused by filamentous fungi responds adequately to medical management. Therapeutic keratoplasty continues to remain an important treatment modality in infections with Candida sp. Early diagnosis with prompt identification of the pathogenic organism is mandatory to initiate appropriate therapy and thereby reduce morbidity.

Candida keratitis: emerging problem in India.

Purpose To determine the epidemiological characteristics and outcome of Candida keratitis in a Cornea Care Unit of Kolkata-based tertiary eye hospital. Methods A retrospective, noncomparative, observational case series involving patients of culture-proven fungal keratitis from January 2008 to December 2008. A total of 85 cases of culture-proven fungal keratitis were identified. Of these, 16 cases were caused by Candida sp and selected for the study. The records were analyzed for demographics, risk factors, mode of management (medical or surgical), indication of surgical therapy, and the response to treatment with final outcome. Medical therapy consisted of topical amphotericin B with or without intracameral application after obtaining culture reports. Surgical therapy included application of tissue adhesive with bandage contact lens and therapeutic keratoplasty. Results All cases of Candida keratitis were caused by Candida albicans accounting for 16 cases [18.81%; 95% confidence interval (CI), 11.8–28.5] of total culture-positive fungal keratitis. We found postsurgical steroid therapy in 8 cases as most important association, followed by diabetes and trauma (4 cases each) as next common comorbidities. All patients required therapeutic keratoplasty. Surgical indications were corneal melt in 10 cases (62.5%; 95% CI, 38.5–81.6), extension up to limbus in 2 cases (12.5%; 95% CI, 12.2–37.2) and nonresponse with worsening in 4 cases (25%; 95% CI, 19.7–49.9). Final outcome consists of phthisis bulbi in 3 cases (18.8%; 95% CI, 5.8–43.8), failed graft in 7 cases (43.7%; 95% CI, 23–66.8), and clear graft in 6 cases (37.5%; 95% CI, 18.4–61.5). Conclusions Candida is a new concern in developing countries like India. We are concerned about the poorer outcome, probably resulting from our unpreparedness and failure of medical therapy leading to more complication and requiring surgical intervention in higher numbers.

Characteristics of microsporidial keratoconjunctivitis in an eastern indian cohort: A case series

BACKGROUND Microsporidia are intracellular parasites responsible for human infections. Recently, there has been an increase in the incidence of microsporidial keratoconjunctivitis (MKC) affecting normal individuals worldwide. AIM To determine the characteristics of MKC in an Indian cohort. MATERIALS AND METHODS This is a retrospective, noncomparative, observational case series, involving patients with MKC between June and September 2009. Of the 24 patients identified, microbiological confirmation in direct smear was obtained in 22 cases and selected. Standard microbiological workup was performed in all the cases. We studied the demographics, predisposing conditions, antecedent treatment received before presentation, clinical characteristics, treatment offered, and resolution time with sequel. The management consisted of simple debridement and application of chloramphenicol ointment (1%) two times a day. RESULTS Mean age of onset was 18.7 years (95% CI, 15.7-21.7; range, 11-36 s years). All patients gave history of prior outdoor activity and exposure to rain water/mud. Antecedent treatment comprised of Acyclovir eye ointment (45.4%) and antibiotic eye drop (27.3%) most commonly. Microsporidia were identified in Gram stain (81.8%), 10% potassium hydroxide mount (72.7%), modified Ziehl-Neelsen staining (36.4%), and Giemsa (18.2%). Majority presented as unilateral superficial keratoconjunctivitis with punctate epithelial keratitis. Mean resolution time was 9 days (95%CI, 7.9-10.2). CONCLUSIONS MKC can occur in normal patients with exposure to rain and mud, related to outdoor activity often misdiagnosed as viral ocular infections. Strong clinical suspicion with proper microbiological evaluation helps to diagnose this commonly misdiagnosed condition.

Bacterial keratitis after manual descemet stripping endothelial keratoplasty--a different pathophysiology?

Purpose: To report two cases of infective keratitis caused by Pseudomonas aeruginosa after manual descemet stripping endothelial keratoplasty (DSEK). Method: Case report. Results: Case 1, a 65-year-old woman, presented with a central corneal infiltrate after manual DSEK for pseudophakic bullous keratopathy, 6 weeks before this presentation. Case 2, a 55-year-old woman, developed a paracentral infiltrate after 7 weeks of undergoing DSEK. Both cases demonstrated Pseudomonas aeruginosa. The risk factors were analyzed. Both the eyes were treated with ciprofloxacin (0.3%) eye drop, while topical dexamethasone (0.1%) was used additionally in the second case. Resolution occurred after 48 days (case 1) and 21 days (case 2), respectively. Although the DSEK failed in case 1, the graft is clear in case 2 at 3 months. Conclusions: Microbial keratitis after DSEK is a new area of concern in the postoperative period, both in developed and in developing countries, with a poor impact on graft outcome. Surface-related factors may predispose to this condition, particularly in pseudophakic bullous keratopathy, countering the advantage gained from absence of suture-related infections common after conventional keratoplasty. The location of the ulcer may have an impact on outcome, as also the inflammatory status. Judicious use of topical steroids early in the course of the disease may improve the immediate graft survival.

Candida fermentati: a rare yeast involved in fungal keratitis.

Purpose: The aim of this study was to report a rare case of fungal keratitis from Eastern India. Methods: This is a case report. Results: A 52-year-old man with a history of minor trauma presented with a total corneal ulcer and hypopyon in the left eye. Microbiologic examination of corneal scrapings showed yeast cells in direct smear and typical yeast colonies on multiple solid agar media. Identification of the organism isolated in the culture was performed using the D1/D2 region of the large subunit (LSU 28S rDNA)–based molecular technique. Polymerase chain reaction amplified a band with a sequence that was 100% homologous with that of Candida fermentati. The organism was susceptible to amphotericin B and anidulafungin and demonstrated resistance to voriconazole, itraconazole, and fluconazole. Therapeutic keratoplasty was performed, followed by the recurrence of the infection in the graft, which was controlled with topical and intracameral amphotericin B. At the end of 3 months, the affected eye had developed phthisis bulbi. Conclusions: This is the first report of isolation of C. fermentati, a species closely related to Candida guilliermondii, from keratitis. Molecular diagnostic techniques are helpful in the accurate identification of this organism, which is clinically important in view of an antifungal susceptibility pattern that differs from that of other yeasts and for selection of appropriate therapy.

Cystic Epithelial Ingrowth in a Case of Deep Anterior Lamellar Keratoplasty

Report of a Case. A 33-year-old man had mild photophobia and redness in his right eye with blurred vision 1 month after an uneventful bilateral LASIK procedure using the same blade for both eyes. Slitlamp examination revealed mild ciliary injection and a white corneal infiltrate in the interface 1.5 mm from the flap edge, with no overlying epithelial defect. With suspicion of bacterial keratitis, topical treatment with ciprofloxacin hydrochloride (Oftacilox) and tobramycin (Tobrex) was initiated. After the first week, the inflammation was reduced but the infiltrate increased in size; thus, lifting and scrapping were performed and samples were obtained from the stromal bed of the ulcer. The microbiological study revealed multiple acid-fast bacilli; therefore, treatment was initiated with amikacin, 0.1%, clarithromycin, 1%, vancomycin hydrochloride, 1%, moxifloxacin, 0.3% (Vigamox), and oral clarithromycin. The intensive treatment failed to control the infection and the infiltrate coalesced, with new satellite lesions appearing (Figure 1). The final result of the culture showed M chelonae resistant to amikacin and clarithromycin; thus, topical linezolid (2 mg/mL) was initiated (6 times daily). Both the infiltrate and the inflammation improved dramatically after the first week of treatment. Control of the infection was achieved after 2 months (Figure 2). Although the final examination revealed a subtle leukoma, the final visual acuity was 20/30 OD and 20/40 OS.

Systemic Evaluation on Antifungal Susceptibility of Keratitis Associated Fungal Pathogens in Eastern India

Assessment of the keratitis associated fungal pathogens and realizes their antifungal sensitivity pattern in Eastern India for better guidance and appropriate choice of antifungal drugs was made. A retrospective, non-comparative study was conducted on 248 fungal keratitis patients between August’2009-July’2012. Corneal scraping was performed and evaluated antifungal susceptibility in all cases. Culture positive fungal keratitis were found in 77.82% cases in which the most predominating pathogen was Aspergillus sp of 46.63% including Aspergillus fumigatus in 41 cases (45.55%) and Aspergillus flavus in 25 cases (27.77%). Aspergillus sp was mostly sensitive to voriconazole next to natamycin and amphotericin B. The second most common pathogen was Candida albicans in 36 cases (18.94%). Candida sp was mostly sensitive to amphotericin B followed by natamycin. Candida sp was relatively insensitive to fluconazole and voriconazole. The third common fungal pathogen was Fusarium sp in 30 cases, among them F. solani in 27 cases (90%). Fusarium sp was mostly sensitive to voriconazole next to natamycin. Aspergillus, Candida and Fusarium were insensitive to fluconazole, micronazole and itraconazole. Aspergillus sp is the most common pathogen of fungal keratitis followed by Candida and Fusarium sp. Voriconazole is still the first choice in the treatment of mould keratitis. Early diagnosis and treatments are vital for better management of fungal keratitis.