Management of Mycotic Management of Mycotic KeratitisKeratitis

Chief author: Sudesh Kumar Chief author: Sudesh Kumar AryaArya

Co-authorsCo-authors: Anamika Garg: Anamika Garg Jagdish Chander Jagdish Chander

Archana Malik Archana Malik Sunandan SoodSunandan Sood

The Authors have no financial interest

ID : 325

Department of Ophthalmology and Microbiology Government Medical College & Hospital

Chandigarh,India

Infective keratitis is a suppurative infection of cornea which may be

associated with epithelial defects and / or signs of inflammation.

FungiFungi - responsible for nearly - responsible for nearly 1/31/3rdrd of infective keratitis of infective keratitis

Mycotic keratitis remains a diagnostic and therapeutic challenge to Mycotic keratitis remains a diagnostic and therapeutic challenge to thethe

ophthalmologist. Difficulties are related to establishing a clinical ophthalmologist. Difficulties are related to establishing a clinical diagnosis, isolating the etiologic fungal organism in the laboratory, diagnosis, isolating the etiologic fungal organism in the laboratory, and treating the keratitis effectively with topical antifungal agents and treating the keratitis effectively with topical antifungal agents or by surgery.or by surgery.

Aim of the StudyAim of the Study To find out demographic profile, type of intervention and final To find out demographic profile, type of intervention and final

outcome of mycotic keratitis in a tertiary care centre.outcome of mycotic keratitis in a tertiary care centre.

Introduction

Materials and Materials and MethodsMethods

Retrospective analysis of case records of Retrospective analysis of case records of

82 eyes of 82 patients from 2004 – 2009 82 eyes of 82 patients from 2004 – 2009

having mycotic keratitis was done.having mycotic keratitis was done.

Exclusion criteria:Exclusion criteria: Proven case of bacterial or viral keratitisProven case of bacterial or viral keratitis Mixed corneal ulcerMixed corneal ulcer

Demographic profileDemographic profile of patient of patient

Relevant history (Relevant history (Predisposing factorPredisposing factor))

Grading of ulcerGrading of ulcer ( size of ulcer, size of corneal infiltrates, ( size of ulcer, size of corneal infiltrates,

scleral involvement, size of perforation if any)scleral involvement, size of perforation if any)

Microbiological dataMicrobiological data ( Gram stain, KOH stain, Culture ( Gram stain, KOH stain, Culture

sensitivity for bacteria and fungus )sensitivity for bacteria and fungus )

Type of Type of interventionintervention done ( Medical treatment with done ( Medical treatment with

antifungals or mixed treatment, Glue with BCL, TPK, any other antifungals or mixed treatment, Glue with BCL, TPK, any other

like AMT, Cyclocryotherapy, Intracameral or intrastromal like AMT, Cyclocryotherapy, Intracameral or intrastromal

Amphotericin B )Amphotericin B )

Duration of Medical treatment and number of surgical Duration of Medical treatment and number of surgical

interventionsinterventions

Materials and Methods cont…Materials and Methods cont…

Observation and Observation and ResultsResults

82 patients included82 patients included

Age 17-90 years Age 17-90 years (Mean age (Mean age

46.37 yrs)46.37 yrs)

61 males, 21 females 61 males, 21 females (M:F – (M:F –

2.9 : 1)2.9 : 1)

75.6%75.6% from rural background from rural backgroundmales

females

males

females

Feathery margins Fungal plaque with hypopyon

Infilterates with pigmentation Corneal abscess

Various Types of Mycotic Keratitis

Predisposing factorsPredisposing factors

21

3

27

31

0

5

10

15

20

25

30

35

vegetativematter

cowtail injury unknown others

50%

12.20%14.60%

30.50%

9.70%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Onlyantifungals

Mixed Rx Medical Rxwith TPK

Early TPK Otherinterventions

Type of InterventionsType of Interventions

Clear Grafts in Mycotic Keratitis

Results cont…Results cont… KOH positivity was present in 25 patients KOH positivity was present in 25 patients (incidence (incidence

20%).20%).

Culture positivity for fungus was present in 18 patientsCulture positivity for fungus was present in 18 patients

( incidence 14.76%).( incidence 14.76%).

45%45% of the cases of mycotic keratitis eventually of the cases of mycotic keratitis eventually needed needed

TPK.TPK.

9.7% of the patients needed other interventions like 9.7% of the patients needed other interventions like

intracameral Amphotericin B (4.8% cases), AMT (3.7% intracameral Amphotericin B (4.8% cases), AMT (3.7%

cases)cases) and Intrastromal Amphotericin B (1.2% cases) in and Intrastromal Amphotericin B (1.2% cases) in

addition to medical treatment or TPK.addition to medical treatment or TPK.

DiscussionDiscussion 25%-35%25%-35% of cases of fungal keratitis require of cases of fungal keratitis require

performance of a TPK to maintain ocular integrity. performance of a TPK to maintain ocular integrity. (Cornea 2002)(Cornea 2002)

While our study showed that upto While our study showed that upto 45%45% of the cases of the cases

eventually need TPK. eventually need TPK.

Stage at which PKP was doneStage at which PKP was done : :

IndianIndian WesternWestern GMCHGMCH Grade 3 (5-7mm) 6% 75% 71%Grade 3 (5-7mm) 6% 75% 71% Grade 4 (7-10mm) 75% 20% 21%Grade 4 (7-10mm) 75% 20% 21% Grade 5 (Tot.invl.) 10% - 8% Grade 5 (Tot.invl.) 10% - 8%

ConclusionsConclusions Mycotic keratitis is a preventable cause of corneal Mycotic keratitis is a preventable cause of corneal

blindness.blindness.

Prompt clinical diagnosisPrompt clinical diagnosis aided with aided with Microbiological Microbiological

supportsupport is vital for success of Medical Therapy is vital for success of Medical Therapy

Surgical intervention is one of the most important Surgical intervention is one of the most important

modalities for salvaging the eye in mycotic keratitis. modalities for salvaging the eye in mycotic keratitis. Early surgical intervention is advocated if patient is Early surgical intervention is advocated if patient is

not responding to treatment.not responding to treatment. Predisposed persons should be Predisposed persons should be educated for proper educated for proper

safety measuressafety measures