Case Report: Beyond the Blood-retina Barrier: Intravitreal Caspofungin for Fungal Endophthalmitis.

SIGNIFICANCE: Two fungal endophthalmitis cases demonstrate safety and efficiency of intravitreal caspofungin as a new therapy option in fungal endophthalmitis. PURPOSE: The purpose of this study was to evaluate the intravitreal application of caspofungin for the treatment of fungal endophthalmitis because rising resistance to voriconazole and amphotericin B leads to a need for new antifungal therapy options. CASE REPORT: Initially, both patients with fungal endophthalmitis underwent pars plana vitrectomy. Microbiological analysis revealed Aspergillus terreus and Candida dubliniensis, which both possess atypical resistance patterns. Caspofungin has a low bioavailability in the eye when given systemically. It was injected intravitreally into the eyes affected by fungal endophthalmitis. An injection of 100 µg of caspofungin in a volume 0.1 mL was applied repeatedly. Clinical parameters were recorded. Both eyes were stabilized by the treatment. Finally, the intraocular infections with atypical mycotic agents were eliminated. Visual acuity improved to 0.4 logMAR (20/50 Snellen) in the first case and to 1.0 logMAR (20/200 Snellen) in the second case. During the treatment course, we have not seen any toxic effects or damage of intraocular structures related to the intravitreal administration of caspofungin. CONCLUSIONS: In summary, intravitreal caspofungin was effective and well tolerated in both cases. Therefore, caspofungin seems to be a safe and effective intravitreal alternative to voriconazole and amphotericin B in fungal endophthalmitis.

Visual outcome in patients of keratomycosis, at a tertiary care centre in Larkana, Pakistan.

OBJECTIVE: To study the post-treatment visual outcome of fungal keratitis. METHODS: This prospective study was carried out at Chandka Medical College and Hospital, Larkana, Pakistan, from March 2005 to March 2016. Patients with clinical features of fungal keratitis, with positive corneal scrapings for fungi, and those who followed up for a minimum period of three months after recovery from infection were included.Other causes of infectious keratitis were excluded. The clinical diagnosis of fungal keratitis was based on risk factor identification and characteristic non-specific and specific corneal features. Treatment included antifungal preparations, topical and if necessary systemic, in addition to symptomatic measures. SPSS 20 was used for data analysis. RESULTS: Of the 1,130 patients, 750(66.37%) were males and 380(33.63%) were females. The overall mean age was 39.44±12.46 years (range:16-74 years). After the completion of treatment, 590(52.21%) of the eyes just retained visual acuity of not more than counting fingers and 126(11.15%) patients lost their globe. Patients with remaining corneal opacity needed keratoplasty. CONCLUSIONS: Most of the eyes just retained visual acuity of counting fingers while some patients lost their globe.

Study of ocular candidiasis during nine-year period.

BACKGROUND: To determine the clinical features, fungal profiles, treatment outcomes, and factors that are significantly associated with the visual outcomes of eyes with endogenous fungal endophthalmitis (EFE). MATERIAL AND METHODS: The medical records of 17 eyes of 9 patients diagnosed with EFE during January 2005 to December 2013 were reviewed. The collected data included patient characteristics, visual acuities (VAs), length between appearance of the first sign of infection and the first ophthalmic examinations, fungal profiles, and treatment regimen. The main outcome measure was the VA. Statistical analyses were done to detect the factors significantly associated with the visual prognosis. RESULTS: The median age at presentation was 67 years. Seven patients had Candida albicans, and 2 had Candida tropicalis. Eight patients received intravenous fosfluconazole, 4 systemic micafungin, 4 oral itraconazole, and 2 intravenous voriconazole. The minimum inhibitory concentrations of fluconazole against Candida albicans isolated from 5 patients ranged from 0.25 to 1.0 µg/mL. A final VA of ≥20/200 was achieved in 69.2% of the eyes. Multiple regression analysis (r(2) = 0.695) detected both initial logMAR (the Logarithm of the minimum angle of resolution) VA (P = 0.0067) and longer length between onset of symptoms and the first ophthalmic examinations (P = 0.0491) as significant worsen factors for final logMAR VA. CONCLUSIONS: Early ophthalmic consultation, better initial visual acuity, and use of effective systemic antifungal treatment might lead to relatively good visual outcomes in EFE.

Effect of pretreatment with antifungal agents on clinical outcomes in fungal keratitis.

BACKGROUND: To determine if pretreatment with antifungal agents is predictive of worse clinical outcome in a fungal keratitis clinical trial. DESIGN: Non-pre-specified subgroup analysis of a randomized controlled trial in a tertiary hospital. PARTICIPANTS: Three hundred twenty-three fungal ulcer cases with an enrolment visual acuity of 20/40 to 20/400. METHODS: The Mycotic Ulcer Treatment Trial I was a randomized, double-masked trial to determine the optimal treatment for filamentous fungal keratitis at the Aravind Eye Care System, India. Enrolled cases were randomized to receive topical natamycin or voriconazole. Prior antifungal medication use, dose and duration were collected at enrolment. A subgroup analysis was performed to determine if patients using natamycin or azoles at presentation have worse clinical outcomes compared with those who were not pretreated. MAIN OUTCOME MEASURES: Three-month visual acuity (primary), 3-month infiltrate or scar size, corneal perforation and/or transplant and re-epithelialization time. RESULTS: Of the 323 patients enrolled, 44% presented on an antifungal agent. Pretreated patients had larger mean baseline infiltrate size (P < 0.001) and epithelial defect size (P = 0.02). Multivariate regression analysis demonstrated that pretreatment was associated with significantly worse 3-month visual acuity (P = 0.006), larger 3-month scar size (P < 0.001) and increased odds of corneal perforation and/or transplant (P = 0.001). CONCLUSIONS: Fungal keratitis that is smear-positive despite being pretreated with appropriate antifungal agents appears to be a risk factor for worse outcomes, likely a result of initial ulcer severity and treatment failure. These patients may benefit from more aggressive multimodal therapy at a tertiary centre.

A Case of Fungal Keratitis Treated Surgically.

Purpose: Here we report a patient who underwent removal of a retrocorneal plaque and anterior chamber irrigation for acute-stage fungal keratitis. Case report: A 56-year-old woman was referred to the Baptist Yamasaki Eye Clinic, Kyoto, Japan due to refractory infectious keratitis. A white plume infiltration from the superficial to deep corneal stroma was present at the central cornea, and a white giant plaque was present on the posterior surface of the cornea. For diagnostic purposes and to reduce inflammation, the retrocorneal plaque was surgically removed and the anterior chamber was irrigated. Findings obtained from the surgically removed plaque revealed many neutrophils coiled with fibrin and filamentous fungus positive to Fungiflora Y staining. At 1-day postoperative, the amount of inflammation and infiltration were drastically decreased and the infection focus became gradually becoming smaller, finally disappearing at 6-weeks postoperative and with no signs of recurrence. Conclusion: The findings of this study show that surgical intervention can be an effective treatment option for cases of fungal keratitis with retrocorneal plaque.

Analysis of outcomes for intravitreal bevacizumab in the treatment of choroidal neovascularization secondary to ocular histoplasmosis.

PURPOSE: To assess the long-term outcomes of intravitreal bevacizumab (IVB) in the treatment of choroidal neovascularization (CNV) secondary to presumed ocular histoplasmosis syndrome (POHS). DESIGN: Retrospective, comparative case series. PARTICIPANTS: Interventional series of 150 eyes in 140 patients treated for subfoveal or juxtafoveal CNV secondary to POHS from January 2006 to January 2010. INTERVENTION: Intravitreal bevacizumab monotherapy or combination IVB and verteporfin photodynamic therapy (IVB/PDT). MAIN OUTCOME MEASURES: Visual acuity (VA) at 12 and 24 months was analyzed. Secondary outcome measures included the number of injections per year and treatment-free intervals. RESULTS: A total of 117 eyes received IVB monotherapy, and 34 eyes underwent combination IVB/PDT treatment. For all patients, the average pretreatment logarithm of minimum angle of resolution (logMAR) was 0.63 (Snellen equivalent 20/86) with a 12-month logMAR VA of 0.45 (Snellen equivalent 20/56) and a 24-month logMAR VA of 0.44 (Snellen equivalent 20/55). The mean follow-up was 21.1 months with an average of 4.24 IVB injections per year. There was no significant difference in initial VA, VA at 12 months, VA at 24 months, or number of eyes with a 3-line gain between the IVB monotherapy and IVB/PDT groups. Thirty-eight percent (39/104) of eyes gained 3 lines or more, and 81.2% (84/104) of subjects had maintained or improved their starting VA at 1 year. The proportion of subjects maintaining a 3-line gain in VA was relatively preserved at 2 years (29.8%, 17/57) and 3 years (30.3%, 10/32) follow-up. There was no increase in the proportion of subjects losing 3 lines or more over 3 years of follow-up. CONCLUSIONS: There is no significant difference in VA outcomes between IVB monotherapy versus IVB/PDT combination therapy. The use of IVB alone or in combination with PDT results in significant visual stabilization in the majority of patients with CNV secondary to POHS.

[Clinical manifestations, treatment and outcome of ocular infections caused by Paecilomyces species].

PURPOSE: To report the predisposing factors, patient background, treatment and outcomes of ocular infections caused by Paecilomyces spp. in Japan. METHODS: We reviewed the medical records and the published literature in Japan on ocular infections caused by microbiologically-proven Paecilomyces spp. Nineteen eyes of 18 patients; 4 eyes of 4 of our patients and 15 eyes of 14 published Japanese patients were studied. RESULTS: Ten men and 8 women (9 OD, 8 OS, 1 OU) were diagnosed with ocular infections caused by Paecilomyces spp. The mean age was 69 years (range 33 to 90 years). The initial diagnosis of ocular infection caused by Paecilomyces spp. was keratitis in 14 eyes and endophthalmitis in 5 eyes. The final diagnosis was keratitis in 2 eyes, keratitis with involvement of the anterior segment of the eye, i.e., hypopyon or corneal rupture, in 12 eyes, and endophthalmitis in 5 eyes. The predisposing factors had a history of ocular surgery, corneal trauma and soft contact lens use. Other factors were diabetes and old age. The infections developed more often in the fall and winter. The identified Paecilomyces spp. had a high sensitivity to micafungin and voriconazole, but low sensitivity to amphotericin B, flucytosine and fluconazole. The prognosis of Paecilomyces spp. ocular infections was very poor, viz., final vision was counting fingers or worse in 60%, ocular perforation in 42%, and eye enucleation in 11%. The percentage of eyes with a final visual acuity worse than counting fingers was 0% in those with keratitis, 50% in those with involvement of the anterior segment, and 100% in those with endophtalmitis (p = 0.0446). Among the antifungal agents, the percentage of cases with final vision of counting fingers or worse was 90% with fluconazole, 80% with itraconazole, 100% with miconazole, and 71% with voriconazole. CONCLUSION: The results show that if the Paecilomyces spp. infection spreads intraocularly, it is difficult to mitigate the clinical damage even with antifungal agents with high sensitivity.

Post-cataract Surgery Fungal Endophthalmitis: Management Outcomes and Prognostic Factors.

Purpose: To describe the clinical and microbiological features, management outcomes, and prognostic factors of visual improvement in post-cataract surgery fungal endophthalmitis.Methods: We evaluated 17 patients with culture-confirmed fungal endophthalmitis following cataract surgery. Data were collected regarding intravitreal antibiotics and antifungals, pars plana vitrectomy (PPV), intraocular lens (IOL) explantation, and scleral-fixated IOL (SFIOL) implantation. Clinical outcomes were recorded in terms of visual acuity and management strategies.Results: PPV was performed as a primary procedure at first presentation in three eyes. Fourteen eyes (82.3%) received intravitreal voriconazole. IOL explantation was performed in four eyes, followed by an SFIOL implantation in three eyes. Six eyes additionally presented with keratitis. At the final follow-up, cases having visual acuity ≥6/60 doubled from 17.6% to 35.3%. Eyes receiving antifungals had a trend toward worse visual outcome.Conclusions: Corneal involvement in addition to endophthalmitis and the presence of Aspergillus terreus were found to be poor prognostic markers.

Pars Plana Vitrectomy for Endophthalmitis: Microbiologic Spectrum and Clinical Outcomes.

Purpose: To report visual outcomes, microbiologic spectrum, and antibiotic resistance in endophthalmitis patients undergoing pars plana vitrectomy (PPV).Methods: Retrospective study of 32 patients who underwent PPV with microbial analysis. Linear mixed models were utilized to compare visual acuity (VA).Results: Streptococcal species and coagulase-negative staphylococcus (CoNS) were the most common organisms. No resistance to vancomycin or fluoroquinolones was observed. Culture-negative individuals had better VA and lower incidences of retinal detachment (RD) and hypotony and better VA than culture-positive group at post-surgical month 3 (p = .025) and marginally at month 12 (p = .098). CoNS endophthalmitis (final logMAR VA 0.80) was associated with better VA than Streptococcal endophthalmitis (final logMAR VA 2.36) (p = .001). Secondary RD was observed in 33.3% of non-cataract endophthalmitis.Conclusion: No organisms were resistant to vancomycin or fluoroquinolones. Culture-negative endophthalmitis had better VA and lower rates of RD and hypotony than culture-positive group. A high rate of RD was observed in non-cataract endophthalmitis.

Association of Postfungal Keratitis Corneal Scar Features With Visual Acuity.

Importance: Corneal opacity is a leading cause of visual impairment worldwide; however, the specific features of corneal scars, which decrease visual acuity, have not been well characterized. Objective: To investigate which features of a postfungal keratitis corneal scar contribute to decreased visual acuity after an episode of infectious keratitis and evaluate whether any corneal features may be used as outcomes for clinical trials. Design, Setting, and Participants: In this ancillary, prospective cross-sectional study, a subset of study participants treated for fungal keratitis (n = 71) as part of the Mycotic Ulcer Treatment Trial I (MUTT I) underwent best spectacle-corrected visual acuity (BSCVA) and best contact lens-corrected visual acuity examination, Scheimpflug imaging, and anterior segment optical coherence tomography at a referral hospital in India approximately 2 years after enrollment. Data were collected from December 3, 2012, to December 19, 2012, and analyses were performed from December 2, 2013, to October 2, 2019. Main Outcomes and Measures: Linear regression models were used to evaluate the importance of various corneal features for BSCVA and to assess whether these features could be used to differentiate the 2 treatment arms of the MUTT I trial. Results: Seventy-one patients (42 men [59.1%]; median age, 48 [range, 39-60] years) were examined at a median (IQR) time of 1.8 (1.4-2.2) years after enrollment. The mean (SD) logMAR BSCVA was 0.17 (0.19) (Snellen equivalent, 20/32). In multivariable linear regression models, BSCVA was most associated with irregular astigmatism (1.0 line of worse BSCVA per 1-line difference between BSCVA and contact lens visual acuity; 95% CI, 0.6-1.4) and corneal scar density (1.5 lines of worse vision per 10-unit increase in the mean central corneal density; 95% CI, 0.8-2.3). The thinnest point of the cornea was the metric that best discriminated between the natamycin- and voriconazole-treated ulcers in MUTT I, with 29.3 µm (95% CI, 7.1-51.6 µm) less thinning in natamycin-treated eyes. Conclusions and Relevance: Both irregular astigmatism and corneal scar density may be important risk factors for BSCVA in a population with relatively mild, healed fungal corneal ulcers. The thinnest point of the corneal scar may be a cornea-specific outcome that could be used to evaluate treatments for corneal ulcers.

The role of pars plana vitrectomy in the management of fungal endogenous endophthalmitis.

PURPOSE: To identify the causative microorganism of fungal endogenous endophthalmitis in our tertiary referral uveitis center and review the therapeutic role of pars plana vitrectomy in patients with fungal endogenous endophthalmitis. METHODS: Seven eyes of six cases were identified as fungal endogenous endophthalmitis through positive cultures of ocular fluids and clinical presentations. The final anatomical and functional results were evaluated. RESULTS: Four women (66.7%) and two men (33.3%) underwent vitrectomy. Control of infection was achieved early on in all cases. Candida (71.4%) and Aspergillus (28.6%) species were identified as causative fungi in patients with fungal endogenous endophthalmitis. Two patients were reoperated due to reinfection and retinal detachment, respectively. Visual acuity improved in six eyes (85.7%) and worsened in one eye (14.3%). At the final examination, the retina was flat in all cases. No eye developed phthisis bulbi. CONCLUSION: Candida species are the most common causative organisms of fungal endogenous endophthalmitis in this study. Pars plana vitrectomy in fungal endogenous endophthalmitis may enhance the treatment of infection by removing fungal elements in the vitreous and aid in diagnosis. Vitrectomy may also be an important tool in the management of vision-threatening post-infectious sequelae such as retinal detachment and reinfections.

Epidemiologic aspects and clinical outcome of fungal keratitis in southeastern Brazil.

PURPOSE: Fungal keratitis (FK) is a sight-threatening disease, more prevalent in developing regions. The present retrospective study was conducted in order to evaluate the epidemiologic and clinical aspects and the progression of FK in patients treated at two ophthalmologic reference centers in Southeast Brazil. METHODS: The charts of patients with infectious keratitis treated between 2000 and 2004 were reviewed. For the 66 cases of FK confirmed by microbiological analysis, data related to patient, disease, and therapeutic approaches were obtained. RESULTS: Mean patient age was 40.7+/-16 years. Fifty-three were men and 13 were women. Ocular trauma occurred in 40% of cases (27). Previous medications taken by the patients were quinolone in 72.5% and antimycotics in 30%. Visual acuity (VA) at presentation was >0.3 in 16% and <0.1 in 74.5%. Penetrant keratoplasty was performed in 38% and evisceration in 15%. The causing agents were Fusarium sp in 67%, Aspergillus sp in 10.5%, and Candida sp in 10%. Medication alone resolved 39% of cases within a mean period of 24.5+/-12 days. Final VA was >0.3 in 28%, and <0.1 in 63%. CONCLUSIONS: Fungal keratitis presented as a disease with severe complications, predominantly among young males, and was mostly caused by filamentous fungi. The present information permits the establishment of preventive strategies. Reducing the time between onset and treatment and using more accessible specific medication would reverse the negative prognosis.

Differences in clinical ocular outcomes between exogenous and endogenous endophthalmitis caused by Sporothrix: a systematic review of published literature.

BACKGROUND: Sporotrichosis is an implantation mycosis caused by Sporothrix species prevalent worldwide, which occasionally can also result in intraocular infection presenting as an exogenous or endogenous infection (disseminated sporotrichosis). Knowledge in its clinical recognition and management is limited. AIMS: To systematically review and analyse data from published literature with a view to comparing clinical outcomes between exogenous and endogenous endophthalmitis caused by Sporothrix. METHODS: Case reports of intraocular sporotrichosis, published from 1960 to 2016, were retrieved from MEDLINE, Embase, Cochrane, LILACS and SciELO databases. The entire data set was divided into two patient groups: (1) exogenous endophthalmitis and (2) endogenous endophthalmitis. Primary outcomes were differences in ocular findings and clinical ocular outcomes between the two groups. RESULTS: From 16 publications retrieved, a total of 8 eyes of 8 patients with exogenous endophthalmitis and 13 eyes of 10 patients with endogenous endophthalmitis were identified. Compared with exogenous endophthalmitis, endogenous endophthalmitis was more common in patients infected with HIV (p=0.001) and those from hyperendemic areas (p=0.036). Anterior uveitis (p=0.015) and posterior uveitis (p=0.04) were more common in the exogenous and endogenous endophthalmitis groups, respectively. The majority of patients with endogenous endophthalmitis had partial or full clinical resolution of ocular lesions with systemic amphotericin B alone or in combination with an oral antifungal, whereas patients with exogenous endophthalmitis had poor outcomes with irreversible vision loss, enucleation and evisceration. CONCLUSIONS: Anterior uveitis is more common in exogenous endophthalmitis with worse overall outcomes and complications, compared with endogenous endophthalmitis where posterior uveitis is the most common clinical manifestation, especially in patients infected with HIV and those from hyperendemic areas. Sporothrix infection should be included in the differential diagnosis for ocular inflammation, regardless of the presence or absence of autoimmune comorbidities and whether the patient resides in an endemic area or not. Ophthalmologists should consider intravitreal and systemic antifungal therapy for exogenous and endogenous endophthalmitis caused by Sporothrix.

Eye for an eye: near-fatal outcome of fungal infection in a young, diabetic girl.

In this report, we describe the case of a young, diabetic girl with ketoacidosis who suffered sudden loss of vision of the right eye. The loss of vision was caused by an invasive rhino-orbital-cerebral fungal infection (mucormycosis) with extensive periorbital thrombosis. Despite maximal antifungal and surgical treatment (including exenteration of the right orbit), the clinical situation deteriorated. It was only after overcoming the difficulties of managing her hyperglycaemia that the patient's condition stabilised and her life was saved. Another factor contributing to this girls' survival was the swift diagnosis of mucormycosis, which was made soon after the onset of symptoms. Because of this, treatment could be started almost immediately.

Evaluation of minimum clinically meaningful changes in scores on the National Eye Institute Visual Function Questionnaire (NEI-VFQ) SST Report Number 19.

PURPOSE: To evaluate responsiveness of the National Eye Institute Visual Function Questionnaire (NEI-VFQ) to changes in visual acuity and to provide estimates of minimum clinically meaningful changes in NEI-VFQ scores. METHODS: Data were combined from three clinical trials of submacular surgery for subfoveal choroidal neovascularization. Patients who completed NEI-VFQ interviews and visual acuity measurements at baseline and 2 years later contributed data for analysis. Data were analyzed using anchor-based (relating 2-year change in NEI-VFQ to 2-year change in visual acuity using correlation and linear regression) and distribution-based (standardized response mean) methods. RESULTS: Of 1,015 patients enrolled, 828 patients completed NEI-VFQ interviews and had visual acuity measurements at baseline and 2 years later. Median age of patients was 75 years (range 18 to 94); all patients had subfoveal choroidal neovascularization in at least one eye. Median overall NEI-VFQ score at baseline was 69.9 (mean, 66.5). Based on anchor-based methods, a 2-line change in visual acuity of the better-seeing eye translated to a 3.4-point change in the overall NEI-VFQ score and from 2.4-point to 7.0-point changes in most subscale scores. The NEI-VFQ was sensitive to both gains and losses in visual acuity; the standardized response mean for the overall NEI-VFQ score in patients with a 2-line gain was 0.6 and for patients with 2-line loss was -0.3. In the subgroup of patients with a 2-line loss of visual acuity in the better-seeing eye, patients who had overall NEI-VFQ scores at baseline greater than the median (59.8) had an standardized response mean of -0.9 for the overall NEI-VFQ score and patients who had overall NEI-VFQ scores at baseline at or below the median had a standardized response mean of 0.2 for the overall NEI-VFQ score. A 4-point change in the overall NEI-VFQ and a 5-point change in individual subscale scores corresponded to a small clinically meaningful change. CONCLUSIONS: The NEI-VFQ was responsive to 2-year changes in visual acuity but was less responsive to changes among patients with poorer NEI-VFQ scores at baseline. Based on this analysis, a 4-point change in the overall NEI-VFQ and a 5-point change in individual subscale scores may be considered minimum clinically meaningful within-person changes in NEI-VFQ scores.

Comparison of micafungin and fluconazole for experimental Candida keratitis in rabbits.

PURPOSE: To evaluate the efficacy of subconjunctival injection of micafungin in the treatment of experimental Candida albicans keratitis in rabbits compared with fluconazole. METHODS: In 1 eye of 24 New Zealand white rabbits, C. albicans (5 x 10 yeast cells) was inoculated in the corneal stroma. The animals were randomly assigned to 3 groups and received subconjunctival injection of 0.5 mL of 0.1% micafungin, 0.2% fluconazole, or physiologic saline once a day for 3 weeks. The eyes were examined slit-lamp biomicroscopically and histopathologically. The clinical course of fungal keratitis was compared among the 3 groups. In another 36 rabbits, a microbiological examination was performed using a quantitative isolate recovery technique, and the numbers of colony-forming units were compared among groups. RESULTS: The clinical scores were significantly lower in the micafungin group than in the other 2 groups throughout the study period (P < 0.0001 approximately P = 0.0027, Bonferroni multiple comparison). The fluconazole group showed significantly lower clinical scores than the saline group on day 18 (P = 0.0343). At the end of the study period, there were significant differences between the saline and micafungin groups (P < 0.0001), the saline and fluconazole groups (P = 0.0072), and the fluconazole and micafungin groups (P = 0.0013). Histopathologically, similar results were obtained. Moreover, the results of the microbiological examination nearly matched the clinical and histopathologic findings. CONCLUSIONS: Subconjunctival administration of micafungin was effective in the treatment of experimental Candida keratitis. Local application of micafungin to the eye would be a feasible treatment option for clinical fungal keratitis.

Amniotic membrane transplantation for persistent corneal ulcers and perforations in acute fungal keratitis.

PURPOSE: To report the therapeutic effect and complications of amniotic membrane transplantation (AMT) in acute fungal keratitis. METHODS: Diagnosis of fungal keratitis was confirmed by cultures in 23 eyes of 23 patients. The indications to perform AMT were to promote reepithelialization in non-healing ulcers or to prevent corneal perforation. Antifungal agents were administered throughout the whole course of hospitalization. Repeated cultures were performed immediately before AMT. The main outcome measurements were epithelial healing rate, necessity of therapeutic penetrating keratoplasty (TPK), and persistence of infection. RESULTS: During a mean follow-up time of 20.6 months +/- 23.22 (6-65 months) AMT was performed during the active phase of the keratitis (fungal culture was still positive) in 16 patients (69.6%), and during the inactive phase (fungal culture negative) in 7 patients (30.4%). Single-layer AMT was performed in 17 patients, and double-layer AMT was performed in 6 patients with corneal perforation and anterior chamber collapse. Complete epithelialization was observed in 12 patients (75%) in the active group and in 7 patients (100%) in the inactive group. Treatment failure requiring TPK was experienced in 4 patients (25%) in the active group. Persistent fungal keratitis was noted in 2 patients (8.7%) in that group. The final visual acuity improved in 17 cases, worsened in 2 cases, and remained unchanged in 4 cases. Twelve of the 23 eyes (52.2%) in this study preserved useful vision (20/400 and better) with or without subsequent surgeries. CONCLUSION: AMT is effective in promoting epithelialization and preventing corneal perforations in acute fungal keratitis, and there is no risk of rejection. However, the risk of persistent or recurrent infection necessitates continued antifungal treatment and patient monitoring.

Raman Spectroscopy Analysis of the Biochemical Characteristics of Experimental Keratomycosis.

PURPOSE: To investigate the biochemical characteristics in experimental keratomycosis by Raman spectroscopy analysis in vitro and in vivo. METHODS: Raman spectroscopy was used to analyze the biochemical characteristics of cultured mouse keratocytes stimulated by Fusarium solani suspension in vitro, and the infected cornea of Fusarium solani keratitis of mice. RESULTS: The peak intensities at 1005, 1186, 1311, 1449 and 1657 cm-1, which represented phenylalanine, tyrosine, nucleic acid bases, phospholipids and α-helix, were decreased in the infected keratocytes compared with the control keratocytes. The consistency of Raman spectra between the infected cornea tissue and the control cornea tissue was high. However, the intensity of some peaks declined, especially at 853, 940 and 1244 cm-1, which represent the tyrosine, proline and collagen content, respectively. CONCLUSIONS: After infection with Fusarium solani, the biochemical characteristics of keratocyte and cornea showed a decrease of amino acids, nucleic acid phospholipids and collagen, which may closely relate to the pathophysiology of keratomycosis.

Cross-Linking Treatment and Corneal Transplant in Refractory Acremonium Keratitis: Case Report.

OBJECTIVES: To report a case of Acremonium keratitis treated with voriconazole, corneal collagen cross-linking, and corneal transplant. MATERIALS AND METHODS: Case report. RESULTS: A 42-year-old woman who wore contact lenses daily was referred for refractory keratitis. Her main complaints were gritty sensation and pain. At slit lamp biomicroscopy, an infiltrate on the inferior paracentral cornea and an arcuate conjunctival ulceration were evident. The rest of the cornea was clear with no anterior chamber reaction. Scrapings from the corneal ulcer showed Candida parapsilosis and Acremonium species, which were sensitive to voriconazole. Despite the administration of topical, systemic, and intrastromal voriconazole for 1 month, repeat corneal scraping was positive for Acremonium, and clinical appearance and pain did not resolve. Therefore, corneal collagen cross-linking was applied. Although the pain resolved immediately after the procedure, the lesion showed no improvement. After a month of cross-linking, corneal transplant was performed for visual rehabilitation and treatment of the refractory lesion. The excised corneal button was negative for any microorganisms. CONCLUSIONS: Although corneal collagen cross-linking may be an effective treatment for Acremonium keratitis refractory to medical therapy, corneal transplant was required for visual gain and recovery.