Endogenous Fungal Endophthalmitis following COVID-19 Hospitalization: Evidence from a Year-Long Observational Study.

PURPOSE: To describe cases of endogenous fungal endophthalmitis (EFE) post-recovery from or hospitalization for coronavirus disease 2019 (COVID-19). METHODS: This prospective audit involved patients with suspected endophthalmitis referred to a tertiary eye care center over a one-year period. Comprehensive ocular examinations, laboratory studies, and imaging were performed. Confirmed cases of EFE with a recent history of COVID-19 hospitalization±intensive care unit admission were identified, documented, managed, followed up, and described. RESULTS: Seven eyes of six patients were reported; 5/6 were male, and the mean age was 55. The mean duration of hospitalization for COVID-19 was approximately 28 days (14-45); the mean time from discharge to onset of visual symptoms was 22 days (0-35). All patients had underlying conditions (5/6 hypertension; 3/6 diabetes mellitus; 2/6 asthma) and had received dexamethasone and remdesivir during their COVID-related hospitalization. All presented with decreased vision, and 4/6 complained of floaters. Baseline visual acuity ranged from light perception (LP) to counting fingers (CF). The fundus was not visible in 3 out of 7 eyes; the other 4 had "creamy-white fluffy lesions" at the posterior pole as well as significant vitritis. Vitreous taps were positive for Candida species in six and Aspergillus species in one eye. Anti-fungal treatment included intravenous amphotericin B followed by oral voriconazole and intravitreal amphotericin B. Three eyes underwent vitrectomy; the systemic health of two patients precluded surgery. One patient (with aspergillosis) died; the others were followed for 7-10 months - the final visual outcome improved from CF to 20/200-20/50 in 4 eyes and worsened (hand motion to LP) or did not change (LP), in two others. CONCLUSION: Ophthalmologists should maintain a high index of clinical suspicion for EFE in cases with visual symptoms and a history of recent COVID-19 hospitalization and/or systemic corticosteroid use - even without other well-known risk factors.

Is mucormycosis the end? A comprehensive management of orbit in COVID associated rhino-orbital-cerebral mucormycosis: preserving the salvageable.

BACKGROUND: Rhino-orbital-cerebral mucor mycosis (ROCM) is a relatively rare opportunistic infection caused by the Mucorales species. While ROCM suggests involvement of the paranasal sinuses, orbit and brain ROM (rhino-orbital-Mucormycosis) stands for the fungal invasion in sinuses and orbit sans cerebral involvement. In India with the outbreak of the second COVID wave and the delta variant of the virus, there has been a steep increase in this opportunistic fulminant fungal infection, named COVID-associated Mucor mycosis (CAM). The most critical question in orbital management is when to go ahead with an exenteration. Our study aims to design a pertinent minimal invasive surgical protocol for surgeons to manage such cases based on our surgical experience and mitigate the need for exenteration and save the eyes wherever possible. METHODS: The study is a retrospective analysis of patients of ROM with and without brain involvement, who underwent minimal surgical management between March 2021 to March 2022 along with their follow-up. RESULTS: There were 184 eyes of 148 patients diagnosed with CAM. The mean age was 51.7 years with a male predominance of 103 (70%). All patients developed ROM following the COVID-19 infection and the duration between diagnosis of COVID-19 and ROM was 36 ± 23 days. 18 cases (12%) were bilateral. 76 eyes (41%) had no vision at the presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (61%), cavernous sinus involvement (53%), and central nervous system (CNS) involvement (47%). All the patients (100%) were treated with systemic Liposomal amphotericin-B and sinus debridement. Endoscopic debridement of the orbital disease was performed in 45 (30.4%) cases, 15(8.1%) eyes underwent exenteration and were later rehabilitated with a customized ocular prosthesis, 103 (56%) eyes underwent transcutaneous retrobulbar amphotericin-B. At a mean follow-up of 13.1 months; the complete resolution was seen in 25 (17%) cases, the residual stable lesion was seen in 77(52%) of the cases and new lesions were developed in 13(9%) of the cases. Mortality was seen in 33 (22%) patients and all of them had CNS involvement. CONCLUSIONS: Systemic and protocol-based management can save the life and salvage the eyes.

Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1.

Purpose: COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management. Methods: This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021. Results: Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05). Conclusion: : Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.

Chronic endogenous fungal endophthalmitis: diagnostic and treatment challenges: A case report.

RATIONALE: Endogenous fungal endophthalmitis (EFE) is a sight-threatening complication of systemic fungemia. As the prevalence rises, treatment remains a challenge especially when there is a failure in first-line treatment or drug-resistant fungus. This case report studies a case of chronic EFE, focusing on the diagnostic procedures, treatment options, monitoring parameters and the treatment outcome. PATIENT CONCERNS: A 64-year-old man with underlying well controlled diabetes mellitus was treated with 2 weeks' course of intravenous antifungal fluconazole for pyelonephritis as his blood culture grew Candida albicans. Concurrently, he complained of 3 months of bilateral painless progressive blurring of vision. At presentation, his visual acuity (VA) was light perception both eyes. Ocular examination revealed non granulomatous inflammation with dense vitritis of both eyes. DIAGNOSIS: He was diagnosed with EFE but the condition responded poorly with the medications. INTERVENTIONS: He was treated with intravitreal (IVT) amphotericin B and fluconazole was continued. Vitrectomy was performed and intraoperative findings included bilateral fungal balls in the vitreous and retina with foveal traction in the left eye. Postoperatively, vision acuity was 6/24, N8 right eye and 2/60, N unable for left eye with extensive left macular scar and hole. Vitreous cultures were negative. He received multiple IVT amphotericin B and was started on topical steroid eye drops for persistent panuveitis with systemic fluconazole. Ocular improvement was seen after switching to IVT and topical voriconazole. Despite this, his ocular condition deteriorated and he developed neovascular glaucoma requiring 3 topical antiglaucoma agents. Panretinal photocoagulation was subsequently performed. OUTCOMES: At 3 months' follow-up, his vision acuity remained at 6/24 for right eye and 2/60 for the left eye. There was no recurrence of inflammation or infection in both eyes. LESSONS: Voriconazole could serve as a promising broad spectrum tri-azole agent in cases of failure in first-line treatment or drug-resistant fungus.

Microsporidial Stromal Keratitis: Epidemiological Features, Slit-Lamp Biomicroscopic Characteristics, and Therapy.

PURPOSE: Microsporidial stromal keratitis is a rare form of infectious keratitis, with only 7 cases reported in the United States to date. This study was performed to evaluate risk factors, clinical features, and response to therapy. METHODS: A retrospective review of the medical records of all patients diagnosed with microsporidial stromal keratitis seen in the practices of the authors between 1999 and 2020 was performed. Diagnosis was determined by cytology or histopathology in corneal specimens. Risk factors, presence or absence of distinctive clinical features, and response to medical and surgical therapies were recorded. RESULTS: Nine patients-7M:2F, aged 7 to 99 years-with microsporidial stromal keratitis were identified. Exposures to recreational water and hymenopteran insect bites, both epidemiologically linked risk factors for systemic microsporidial infection, were identified in our patients. Presence of stromal edema with features of disciform keratitis and a distinctive granular keratitis were observed in 6 of 9 and 5 of 9 patients, respectively. Poor response to medical therapy was noted. Penetrating keratoplasty was effective in curing the infection. Final visual acuity was 20/40 or better in 6 of 9 patients. CONCLUSIONS: In patients with slowly progressive keratitis, history of exposure to recreational water or hymenopteran insects should be sought. In patients with corneal edema consistent with disciform keratitis, with evolution to a granular keratitis, microsporidia should be considered in the differential diagnosis. In cases of established microsporidial stromal keratitis, penetrating keratoplasty should be considered if prompt response to medical therapy is not noted.

Unusual presentation of mucormycosis mimicking a localised sino-orbital pathology.

Mucormycosis is an aggressive and deadly fungal infection, which is invariably associated with an immunocompromised patient. Mucormycosis in the head and neck region presents as skeletal necrosis, with or without soft tissue involvement. Early identification and treatment with combination of surgical debridement and parenteral antifungal therapy is critical for a favourable outcome. This paper reports an unusual presentation of mucormycosis, mimicking a localised sino-orbital pathology involving the infraorbital subcutaneous tissue and the maxillary sinus, in a 35 years old immunocompetent man. Despite aggressive antifungal therapy and surgical management, the course of disease was fatal, reiterating the high mortality associated with mucormycosis.

Rhino-orbital mucormycosis: Our experiences with clinical features and management in a tertiary care center.

Objective: To determine the prevalence, risk factors, and elaborate our experiences with diagnosis and treatment of patients with mucormycosis, enabling a better understanding of the disease and its management. Methods: This is a case series of patients with Covid-19 associated with Rhino-orbital-cerebral mucormycosis, managed in our tertiary care center from April 2021 to June 2021. Results: Six cases of Covid-19 associated with Rhino-orbital-cerebral mucormycosis have been analyzed in the study. The mean age of patients was 40.67 years with a male preponderance (83.3%). The most common complaint was headache (100%), while a minority (33%) came with ocular complaints. All the patients either had a previous history of diabetes mellitus or developed increased blood sugar levels following Covid infection, and were kept on insulin to control their blood sugar levels. 4 patients (66.67%) had a history of corticosteroid use during Covid-19 hospitalization. Treatment included intravenous liposomal Amphotericin B (100%), functional endoscopic sinus surgery (66.67%), maxillectomy (33.33%) and transcutaneous retrobulbar liposomal Amphotericin B (33.33%). Amphotericin B induced nephrotoxicity, which was seen in 1 patient (16.67%). Mortality occurred in only one patient (16.67%), 25 days following successful surgery. Conclusion: Diabetes Mellitus is the most important predisposing factor for the development of Covid-19 associated Rhino-orbital-cerebral mucormycosis. Early presentation, prompt diagnosis and timely initiation of treatment with liposomal Amphotericin B and surgical debridement along with strict blood sugar control can lead to a favorable outcome. However, regular follow-up and monitoring of serum electrolytes and kidney profile must be ensured for such patients.

Ocular Phaeohyphomycosis Caused by Veronaea botryose: A Novel Fungal Infection in Human Beings.

PURPOSE: To describe an aggressive, refractory case of Veronaea botryosa-associated mycokeratitis progressing to endophthalmitis. METHODS: Observational case report and review of relevant literature. RESULTS: An 80-year-old man with a history of lung cancer and diabetes mellitus type 2 presented as an emergent referral to the corneal service with a corneal ulcer and associated endothelial plaque that responded initially to topical steroid and antiviral therapy but subsequently progressed to fungal endophthalmitis. The patient underwent an emergent penetrating keratoplasty and pars plana vitrectomy. Despite multiple negative Grocott methenamine silver smears, gram stains, eye cultures (aerobic, anaerobic, and fungal), and inconclusive confocal microscopy, the host corneal tissue pathology revealed melanin-containing fungi (phaeohyphomycosis). Further speciation of the pathology specimen revealed mold and phenotypic characterization and DNA sequencing confirmed V. botryose. CONCLUSIONS: Veronaea botryose is a rare fungal infection with previously reported human cutaneous, subcutaneous, and submucosal infections. This is the first documented case of phaeohyphomycosis caused by V. botryosa infection in human ocular tissue.

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.

Lenticular fungal infection caused by Aspergillus in a patient with traumatic corneal laceration: a case report.

BACKGROUND: To report a case of lenticular infection caused by Aspergillus, which was diagnosed 13 weeks after traumatic corneal laceration. CASE PRESENTATION: A 60-year-old woman presented with traumatic corneal laceration including anterior lens capsule rupture and traumatic cataract after being hit with a chestnut in the right eye. There were multiple injuries due to tiny thorns of the chestnut, including the conjunctiva, sclera, cornea, and anterior lens capsule. But no visible foreign body was detected by slit-lamp examination. Topical corticosteroid was prescribed to resolve the conjunctival inflammation induced by the thorns of chestnut, which could have caused persistent irritation. As conjunctival injection and edema being decreased during outpatient clinical follow-up, embedded conjunctival foreign body was detected and surgically removed (1st surgery). Approximately 10 weeks after the trauma, severe inflammation of the anterior segment accompanied with hypopyon developed suddenly and at the same time embedded scleral foreign body was revealed. After removal of scleral foreign body (2nd surgery), unspecified mold species was cultured from the scleral foreign body in SDA (Sabouraud dextrose agar) plate. Suspicious corneal foreign body was removed as 3rd surgery and phacoemulsification of traumatic cataract was planned as 4th surgery. Aspergillus was finally detected from removed anterior capsule and fibrotic membrane during the operation. Fungal infection resolved successfully after administration of topical (1% voriconazole and 5% natamycin) and systemic (fluconazole) antifungal agents and phacoemulsification of traumatic cataract. CONCLUSION: Chestnut thorns can damage multiple ocular tissues simultaneously. Lens capsular rupture could result in fungal inoculation and lead to delayed lenticular fungal infection with complicated cataract formation. In cases of ocular trauma due to organic substances such as thorns and branches, the possibility of fungal infection should be considered.

[A clinical analysis of 1 414 cases of fungal keratitis].

Objective: To discuss clinical features and treatments of fungal keratitis, and to provide statistical data for clinical therapy and increase the therapeutic effects. Methods: This is a retrospective case series study. An analysis was performed by collecting patients' demography features, risk factors, onset time, lab results, clinical features and treatment from 1 414 cases of fungal keratitis from January 2006 to October 2016 in Qingdao Eye Hospital, Shandong Eye Institute. Results: In the 1 414 cases (1 414 patients), 1 174 patients (83.0%) came from different areas in Shandong Province, and the rest mainly from provinces on the north of Yangtze River. The age was 40 to 60 years in 874 cases (61.4%). The onset time was often in autumn and winter. The average duration between the onset and treatment was 1 to 74 days; 942 patients (67.1%) visited our hospital in 8-30 days after the appearance of the symptoms. Corneal trauma was the most common risk factor, especially injury by plants (367 cases, 26.4%). The positive rate of direct microscopic examination of potassium hydroxide wet mounts was 96.4%. The positive rate of confocal microscopy was 89.8%. Fungi were detected in corneal ulcer scrapings and (or) diseased corneal tissues obtained during surgery from 973 patients (68.8%). Most of the fungi were Fusarium (595 cases, 61.1%), followed by Alternaria (184 cases, 18.9%) and Aspergillus (119 cases, 12.2%). There were 603 cases (42.7%) of superficial and middle stromal infiltration, 614 cases (43.4%) of deep stromal infiltration and 197 cases (13.9%) of full-thickness corneal infiltration. Diameters of the corneal ulcer lesion were mostly between 4 and 6 mm (725 cases, 51.6%), followed by<3 mm (372 cases, 26.4%) and>6 mm (302 cases, 22.0%). Hypopyon was combined in 498 cases (35.2%), corneal perforation in 34 cases (2.4%), and endophthalmitis in 58 cases (4.1%). Surgery was performed in 1 198 cases (84.8%), including penetrating keratoplasty in 416 cases (29.4%), lamellar keratoplasty in 199 cases (14.1%), and corneal ulcer debridement in 532 cases (37.6%), with an effective rate of 98.1% (408 cases), 97.0% (193 cases) and 92.8% (494 cases), respectively. Two hundred and fifteen cases (15.2%) were treated with medical therapy alone, of which 147 cases (68.4%) were cured. Fifty-six patients (3.9%) finally lost their eye balls, including 54 cases of evisceration and 2 cases of ophthalmectomy. Conclusions: Fusarium is the main causative agent of fungal keratitis in Shandong Province. Direct microscopic examination of potassium hydroxide wet mounts is a simple, rapid and effective test method. Early diagnosis can be made if the result of corneal ulcer scraping examination is positive. Antifungal drug treatments can be done in early onset time. If the drug efficacy is poor or the patient's condition gets worse, immediate surgery is the key to controlling fungal keratitis. (Chin J Ophthalmol, 2020, 56:286-293).

CLINICAL PRESENTATIONS, DIAGNOSIS, AND MANAGEMENT OUTCOMES OF CURVULARIA ENDOPHTHALMITIS AND A REVIEW OF LITERATURE.

PURPOSE: To describe the clinical presentation and management of Curvularia endophthalmitis and compare with previous published literature. METHODS: Retrospective interventional comparative case series and literature review. Eight cases with culture-proven Curvularia endophthalmitis from January 2000 to March 2018 underwent vitrectomy/vitreous biopsy, intravitreal antibiotic with or without additional procedures as appropriate. The undiluted vitreous biopsy was subjected to microbiologic evaluation. Pre-existing literature was reviewed, and the current outcomes were compared with them. The mean age at presentation, etiology, number of interventions, interval between inciting event and presentation, type of intravitreal antifungal used, anatomical, and the functional outcomes were reported and compared with pre-existing literature. A favorable anatomical outcome was defined as preservation of the globe, absence of hypotony, attached retina, and absence of active inflammation at the last visit. RESULTS: In the current series, there were 4 men and 4 women. Mean age at presentation was 34.5 ± 13.51 years (median 30 years). Inciting event was open-globe injury in five cases and cataract surgery, trabeculectomy, and endogenous cause in one case each. Presenting visual acuity was ≥20/400 in 3 cases at presentation and 5 cases at the last visit. One case with staphyloma and endophthalmitis underwent evisceration for a painful blind eye. The patients in the current series were much younger than those described previously. CONCLUSION: Presentation and diagnosis of Curvularia can be delayed especially in postoperative cases. Early and appropriate management with multiple interventions can result in an acceptable visual and anatomical outcome.

In Vitro Efficacy of Chlorhexidine and a riboflavin/UVA Combination on Fungal Agents of Keratitis.

Purpose: Mycotic keratitis is a global ophthalmological problem because it is difficult to diagnose and treat. The aim of the current study was to evaluate the efficiency of using antifungal agents amphotericin B (AMB), voriconazole (VRC), 0.02% chlorhexidine (CHX), and a combination of riboflavin and UVA treatment against two fungal genera (Aspergillus and Fusarium) responsible for keratitis.Methods: We evaluated antifungal efficiencies of riboflavin/UVA and the antifungal drugs VRC, AMB, and CHX (alone and in combination) against fungal inocula at four concentrations. We recorded colony counts of isolates for Aspergillus terreus, A. flavus, A. fumigatus, Fusarium falciforme, F. proliferatum, and F. solani on Mueller-Hinton agar plates.Results: Fungal suspensions exposed to the following treatment combinations did not allow fungal growth: riboflavin/UVA and VRC, riboflavin/UVA and AMB, riboflavin/UVA and CHX, and CHX alone. We observed a statistically significant reduction (P < .05) in the number of colonies on agar plates when fungal suspensions were treated with riboflavin/UVA, VRC, and AMB only.Conclusions: Riboflavin/UVA treatment in combination with AMB, VRC, and CHX are capable of killing keratitis-inducing fungi (P < .05). The antiseptic CHX exerted a considerable antifungal effect on all strains we examined. Therefore, we recommend CHX as additional therapy against mycotic keratitis, particularly when keratitis is caused by multi-resistant members of Fusarium.

Human Pythiosis: Emergence of Fungal-Like Organism.

Pythiosis is an emerging infectious disease caused by the aquatic oomycete Pythium insidiosum, a fungal-like organism. It is believed that P. insidiosum's zoospores, its infected form, play major role in pathogenesis. Vascular and ocular infections are the most common clinical manifestation in humans. It is difficult to establish the diagnosis given its relatively rarity and difficulty to distinguish P. insidiosum from other molds. Delay in diagnosis and treatment has been associated with poor outcomes. High index of suspicion is the key, particularly in thalassemia patients with arterial insufficiency and patients with fungal keratitis/endophthalmitis without improvement on antifungal therapy. Tissue culture and zoospore induction remain gold standard for diagnosis; however, DNA-based method should be performed simultaneously. The combination of radical surgery, antifungal agents, and immunotherapy has been recommended. It was previously believed that surgery with negative surgical margins was the essential to survive in vascular pythiosis; however, it was recently found that patients could have residual disease despite documented negative surgical margins as infected clot may be dislodged to proximal arterial sites prior to surgery. Serum ß-D-glucan (BG) has been used to monitor disease response after treatment initiation in vascular pythiosis. A significant decrease in BG levels within 2 weeks after surgery is indicative of the absence of residual infection. Unfortunately, monitoring tools for ocular pythiosis are not yet available. Itraconazole plus terbinafine have generally been used in P. insidiosum-infected patients; however, antibacterial agents, including azithromycin and linezolid, have also been used with favorable outcomes in ocular disease. Recently, azithromycin or clarithromycin plus doxycyclin were used in two relapsed vascular pythiosis patients with good outcomes.

Estudo epidemiológico das queratites infeciosas internadas num centro hospitalar terciário - revisão de 5 anos / Epidemiological study of infeccious keratitis in inpatients of a terciary hospital center - revision of 5 years

Resumo Objetivo: A queratite infeciosa é uma doença de incidência relativamente elevada e é responsável por um número importante de internamentos. Neste estudo pretende-se estudar diversas características epidemiológicas e clínicas associadas às queratites infeciosas de alto risco num hospital terciário em Portugal. Métodos: Realizou-se um estudo retrospetivo, onde foram incluídos todos os doentes internados por abcesso da córnea no Centro Hospitalar Universitário do Porto (CHUP), entre Abril de 2013 a Março de 2018. Caracterizou-se a população em relação aos fatores de risco, apresentação clínica, tempo de internamento, resultados de culturas, resistência antibiótica in vitro, tratamento efetuado e resultado funcional. Resultados: O estudo incluiu 105 doentes. Os principais fatores de risco foram antecedentes de cirurgia de córnea, uso de lentes de contacto e história recente de trauma ocular. 74,3% dos doentes tiveram cultura positiva com 87,9% a corresponderem a cultura bacteriana pura, sendo a Pseudomonas aeruginosa e o Streptococcus pneumoniae os agentes etiológicos mais frequentes. 27,9% das culturas positivas eram resistentes a 3 ou mais classes de antibióticos. Todos os doentes iniciaram tratamento com colírios fortificados. 29,5% dos doentes necessitaram de realizar transplante de córnea. Ao final de 6 meses de seguimento, apenas 20,9% apresentavam AV>20/40. Conclusão: Na maioria dos casos, a etiologia foi bacteriana. Observou-se um número considerável de bactérias multirresistentes. Apesar do tratamento ter permitido uma melhoria da visão na maioria dos casos, um número considerável de doentes ficou com sequelas visuais importantes.

Abstract Objective: Infectious keratitis is a pathology with a high incidence and is responsible for a large number of prolonged stay hospital admissions. The purpose was to analyze the epidemiological and clinical data associated with high risk microbial keratitis at a central hospital in Portugal. Methods: A retrospective study of all inpatients presenting with corneal abscess in Centro Hospitalar Universitário do Porto, from April 2013 to March 2018 was performed. Target population was characterized by risk factors, clinical features, length of stay, culture results, in vitro antibiotic resistance, treatment and outcome. Results: This study included 105 patients. The main risk factors were previous corneal surgery, contact lenses wear and recent history of ocular trauma. 74.3% of patients had a positive culture, 87.9% of these corresponding to a pure bacterial culture, with Pseudomonas aeruginosa and Streptococcus pneumoniae being the most common pathogens. 27.9% of positive cultures were resistant to 3 or more classes of antibiotics. All patients began treatment with fortified drops. 29.5% of patients required a corneal transplant. After 6 months of follow-up, only 20.9% presented a VA>20/40. Conclusion: Most cases were caused by bacteria. A considerable number of multi-resistant bacteria was identified. Despite most cases having improved after treatment, a large number of patients had a significant visual acuity sequelae.

MSCs helped reduce scarring in the cornea after fungal infection when combined with anti-fungal treatment.

BACKGROUND: Fungal Keratitis (FK) is an infective keratopathy with extremely high blindness rate. The damaging effect of this disease is not only the destruction of corneal tissue during fungal infection, but also the cornea scar formed during the healing period after infection control, which can also seriously affect a patient's vision. The purpose of the study was to observe the effect of umbilical cord mesenchymal stem cells (uMSCs) on corneal scar formation in FK. METHODS: The FK mouse model was made according to a previously reported method. Natamycin eye drops were used for antifungal treatment 24 h after modeling. There are four groups involved in the study, including control group, FK group, vehicleinj FK group and uMSCsinj FK group. Mice in uMSCsinj FK group received repeated subconjunctival injections of uMSCs for 3 times at the 1d, 4d and 7d after FK modeling. At 14d, 21d and 28d after trauma, clinical observation, histological examination, second harmonic generation and molecular assays were performed. RESULTS: The uMSCs topical administration reduced corneal scar formation area and corneal opacity, accompanying with decreased corneal thickness and inflammatory cell infiltration, following down-regulated fibrotic-related factors α-SMA, TGFß1, CTGF, and COLI and finally inhibited phosphorylation of TGFß1/Smad2 signaling pathway during FK corneal fibrosis. CONCLUSION: The results confirmed that uMSCs can improve corneal opacity during the scar formation stage of FK, and exert anti-inflammatory and anti-fibrotic effects.

A case report of infectious scleritis with corneal ulcer caused by Scedosporium aurantiacum.

RATIONALE: Scedosporium species is rare pathogen of ocular infection. The accurate diagnosis is delaying in many cases and the clinical prognosis is poor due to its resistance to antifungal agents. This report describes a patient with infectious scleritis and corneal ulcer caused by Scedosporium auranticum infection who required enucleation to control the infection. PATIENT CONCERNS: A 70-year-old woman visited our clinic after experiencing ocular discomfort in her right eye for 4 days after minor ocular trauma, with soil exposure. DIAGNOSES: Scedosporium species was isolated from a culture of corneal tissue, Scedosporium aurantiacum was identified in a culture of necrotic tissue. INTERVENTIONS: She was started on treatment with antifungal agents, including topical amphotericin B and systemic fluconazole, but her ocular condition did not improve. Although the lesion showed temporary improvement, ocular pain and corneal ulcer recurred 3 months later. Evisceration was performed due to corneal perforation, and enucleation was also performed for dehiscence of the conjunctiva and scleral necrosis. OUTCOMES: After enucleation, postoperative systemic voriconazole treatment controlled the infection without recurrence. LESSONS: S aurantiacum keratitis is difficult to eradicate, even with several months of treatment with systemic and topical antifungal agents, and tends to progress to scleritis. The infection can be terminated by the orbital enucleation. Infection with this rare organism should be included in the differential diagnosis of patients with severe infectious keratitis.

Invasive sino-orbital fungal infections in immunocompetent patients: a clinico-pathological study.

OBJECTIVE: Invasive sino-orbital fungal infections in immunocompetent patients are a rare clinical entity; the diagnosis and management of which is challenging. We present a large case series of invasive sino-orbital fungal granulomas in patients without pre-existing systemic immunocomprimising condition. DESIGN: Retrospective case series. PARTICIPANTS: Twenty cases of invasive sino-orbital/naso-orbital fungal granulomas in immunocompetent individuals. METHODS: We retrospectively analyzed all patients with orbital fungal granuloma who were treated at a tertiary referral eye center in South India between January 2005 and December 2012. Histopathologic confirmation of tissue invasion by fungal elements and presence of granulomatous inflammation was established in all cases included in the study. MAIN OUTCOME MEASURES: Relief of patient symptoms, resolution/no progression of disease on orbital imaging, ocular, and vision salvage were the treatment outcomes studied. RESULTS: Twenty patients (11 male and 9 female) were studied. Mean age of patients was 47.4 years ranging from 24-65 years. Aspergillus was the causative fungus in 18 cases while 2 were cases of mucormycosis. Surgical debulking of the orbital disease was performed in 7 patients. Exenteration was performed in 2 patients to prevent spread to the CNS. Medical therapy consisted of oral itraconazole in all patients and intravenous amphotericin B was administered in 2 patients. Average duration of medical therapy required to achieve relief from symptoms was 6-8 months. Recurrences are common and long-term follow-up is essential. CONCLUSIONS: Orbital fungal infections are challenging in terms of both diagnosis and treatment. Debulking along with prolonged antifungal therapy seems to be effective in controlling the infection.

Bacterial and Fungal Keratitis: A Retrospective Analysis at a University Hospital in Switzerland.

BACKGROUND: Infectious keratitis is a serious corneal disease and may lead to permanent visual deterioration if not treated rapidly and effectively. In order to determine possible changes in the spectrum of pathogens over time, we evaluated the pathogenic organisms of keratitis at a university hospital in Switzerland, comparing two time periods within a decade. METHODS: In this retrospective study, 417 patients with the clinical diagnosis of bacterial or fungal keratitis in 2006/07 and 2015/16 were enrolled. In an additional analysis, all cases of fungal keratitis between 2006 and 2016 were evaluated. Collected parameters were age, gender, side, use of contact lenses, systemic, neurological and ocular diseases, trauma, previous surgery, and systemic and topical therapy before presentation. In each patient, microbiological results of corneal smears such as growth and antibiotic resistance were analysed. RESULTS: A total of 163 and 254 eyes were included in 2006/07 and 2015/16, respectively. In 2006/07, a culture of smears revealed a bacterial cause in 70 eyes (42.9%) and a fungal cause in 4 eyes (2.5%), whereas in 2015/16, bacterial growth was found in 115 eyes (45.3%) and fungal growth in 6 eyes (2.4%). The most common bacteria in 2006/07 and 2015/16 were coagulase-negative Staphylococci (44.3 vs. 49.6%), Pseudomonas aeruginosa (18.6 vs. 13.9%), Staphylococcus aureus (10 vs. 16.5%), Corynebacterium spp. (8.6 vs. 5.2%), and Moraxella spp. (7.1 vs. 9.6%). Candida parapsilosis was the most common fungal isolate in both groups (25 vs. 33.3%). Between 2006 and 2016, fungal keratitis was found in 37 eyes (Candida spp. n = 11, Fusarium spp. n = 11, Aspergillus spp. n = 5, others n = 10). All patients with Fusarium spp. keratitis had a history of wearing contact lenses. CONCLUSION: The most commonly isolated bacterial organisms were Staphylococci and Pseudomonas spp., whereas fungal keratitis was mainly due to Candida spp. or Fusarium spp. No relevant variation in causative pathogens was observed between the two time periods.