Standard terminology and labeling of ocular tissue for transplantation.

PURPOSE: To develop an internationally agreed terminology for describing ocular tissue grafts to improve the accuracy and reliability of information transfer, to enhance tissue traceability, and to facilitate the gathering of comparative global activity data, including denominator data for use in biovigilance analyses. METHODS: ICCBBA, the international standards organization for terminology, coding, and labeling of blood, cells, and tissues, approached the major Eye Bank Associations to form an expert advisory group. The group met by regular conference calls to develop a standard terminology, which was released for public consultation and amended accordingly. RESULTS: The terminology uses broad definitions (Classes) with modifying characteristics (Attributes) to define each ocular tissue product. The terminology may be used within the ISBT 128 system to label tissue products with standardized bar codes enabling the electronic capture of critical data in the collection, processing, and distribution of tissues. Guidance on coding and labeling has also been developed. CONCLUSIONS: The development of a standard terminology for ocular tissue marks an important step for improving traceability and reducing the risk of mistakes due to transcription errors. ISBT 128 computer codes have been assigned and may now be used to label ocular tissues. Eye banks are encouraged to adopt this standard terminology and move toward full implementation of ISBT 128 nomenclature, coding, and labeling.

An outbreak of acute post-cataract surgery Pseudomonas sp. endophthalmitis caused by contaminated hydrophilic intraocular lens solution.

OBJECTIVE: To report the investigation for the source of infection and the clinical course and treatment response of 11 cases of acute post-cataract surgery endophthalmitis that developed during an outbreak. DESIGN: Retrospective, consecutive, interventional case series. PARTICIPANTS: Eleven patients who developed acute postoperative endophthalmitis after an uneventful cataract surgery with intraocular lens implantation from September 6 to 29, 2010, at a tertiary eye care center in South India. METHODS: Aqueous aspirates, vitreous aspirates, and environmental surveillance specimens were sampled. All specimens were subjected to smear and culture. Positive cultures were subjected to antibiotic susceptibility. Genotypic diversity was determined by polymerase chain reaction (PCR) with enterobacterial repetitive intergenic consensus (ERIC) primers of each strain and was used to establish the clonal relationship between clinical and environmental isolates. The clinical patterns were analyzed. MAIN OUTCOME MEASURES: Positive microbiology, molecular diagnostic similarity among the culture positive endophthalmitis cases, and surveillance specimens. RESULTS: Aqueous and vitreous samples showed gram-negative bacilli in the smears of 8 of 11 eyes, and cultures grew Pseudomonas aeruginosa in 5 of 11 eyes. Among the samples from various surveillance specimens cultured, only the hydrophilic acrylic intraocular lenses and their solution grew P. aeruginosa, with antibiotic susceptibility pattern identical to the clinical isolates. The isolates from the patients and the intraocular lens solution revealed matching patterns similar to an American Type Culture Collection (ATCC) strain of P. aeruginosa on ERIC-PCR. The intraocular lenses of the same make were discontinued at our hospital, and the endophthalmitis did not recur. The final visual acuity improved to ≥ 20/50 in 8 of 11 patients (72.7%). One patient developed retinal detachment, but was treated successfully, and 2 other patients progressed to phthisis bulbi. CONCLUSIONS: Positive microbiology and the ERIC-PCR results proved that contamination of hydrophilic intraocular lenses and the preservative solution was the source of infection in this outbreak. Early detection and a planned approach during the outbreak helped us to achieve good visual and anatomic outcomes, even though the offending organism was identified as P. aeruginosa.

External ocular surface and lens microbiota in contact lens wearers with corneal infiltrates during extended wear of hydrogel lenses.

OBJECTIVES: To determine whether carriage of microbes on the contact lens or ocular surfaces during extended wear (EW) with soft hydroxyethyl methacrylate (HEMA)-based contact lenses predisposes the wearer to adverse events. METHODS: Participants (non-contact lens wearers) were enrolled in a clinical study involving wear of HEMA-based hydrogel lenses on a six night EW basis with weekly replacement. Type and number of bacteria colonizing the lower lid margins, upper bulbar conjunctiva, and contact lenses during EW after one night, 1 week, 1 month, and thereafter every 3 months for 3.5 years were determined. The association of bacteria with adverse responses was compared between carriers (defined as having significant microbes cultured from two or more samples with 1 year) and noncarriers, and the strength of the association was estimated using multivariate logistic regression. RESULTS: Carriers of gram-positive bacteria on lenses (particularly coagulase negative staphylococci or Corynebacterium spp.) were approximately three and eight times more likely to develop contact lens-induced peripheral ulcers (CLPUs) and asymptomatic infiltrates (AIs), respectively. Staphylococcus aureus was most frequently isolated from lenses during CLPU. Carriers of gram-negative bacteria on lenses were five times more likely to develop contact lens-induced acute red eye (CLARE). Haemophilus influenzae was isolated most frequently from lenses during CLARE and AI events. CONCLUSIONS: Bacterial carriage on contact lenses during EW predisposes the wearer to the development of corneal inflammatory events including CLARE, CLPU, and AI.

In vitro antibiotic susceptibility of rapidly growing nontuberculous mycobacteria isolated from patients with microbial keratitis.

PURPOSE: This study was undertaken to determine the antibiotic susceptibility and minimum inhibitory concentrations (MIC) of amikacin, tobramycin, ciprofloxacin, gatifloxacin, azithromycin, and clarithromycin against rapidly growing nontuberculous mycobacteria isolated from patients with keratitis. METHODS: A total of 15 rapidly growing nontuberculous mycobacteria isolated from corneal scrapings of keratitis patients from January 1999 through December 2007 were subjected to antimicrobial susceptibility testing by the E-Test to amikacin, tobramycin, ciprofloxacin, gatifloxacin, azithromycin, and clarithromycin. RESULTS: Out of 15 isolates, 13 were identified as Mycobacterium chelonae complex and 2 as Mycobacterium fortuitum complex. Based on minimum inhibitory concentration (MIC) cut off, all 15 (100%) isolates were sensitive to amikacin, azithromycin, and clarithromycin, 13 (86%) were sensitive to tobramycin, nine (60%) to gatifloxacin, and only 6 (40%) to ciprofloxacin. The MIC range was 0.25-4 microg/ml for amikacin, 0.5-1 microg/ml for azithromycin, 0.125-1 microg/ml for clarithromycin, 0.5-16 microg/ml for ciprofloxacin, and 0.25-16 microg/ml for tobramycin. MIC(90) for amikacin was 2 microg/ml, azithromycin 1 microg/ml, clarithromycin 0.75 microg/ml, ciprofloxacin 8 microg/ml, gatifloxacin 8 microg/ml, and for tobramycin it was 4 microg/ml. CONCLUSIONS: All the isolates were sensitive to amikacin, azithromycin, and clarithromycin, but the MIC values of clarithromycin and azithromycin were lower than amikacin. Based on in vitro susceptibility results it appears that the topical amikacin in combination with oral clarithromycin or azithromycin is the best treatment option for rapidly growing nontuberculous mycobacterial keratitis.

Microbial keratitis after LASIK.

PURPOSE: To report cases of microbial keratitis after LASIK from a tropical climatic zone. METHODS: This retrospective case series included 17 eyes of 15 patients managed at our center from January 1999 to December 2007. All patients had a detailed clinical evaluation followed by corneal scrapings. The material obtained on scraping was subjected to detailed microbiology evaluation. Initial medical treatment was based on microbiology results and included irrigation of the interface with appropriate antimicrobial solutions. The flap was amputated in patients who developed flap necrosis. N-butyl cyanoacrylate tissue adhesive was applied for gross thinning and penetrating keratoplasty (PK) was performed for advanced cases of keratitis. RESULTS: Mean patient age was 25.8 years (range: 18 to 44 years). Two patients had undergone unilateral surgery. Thirteen patients presented with infection in 1 eye and 2 patients had bilateral infection. The microorganisms isolated were filamentous fungi (4 eyes), Nocardia asteroides (5 eyes), atypical mycobacteria (4 eyes), Acanthamoeba (2 eyes), Corynebacterium (1 eye), and Staphylococcus epidermidis (1 eye). The infection resolved with medical treatment in 6 eyes, medical treatment and flap amputation in 4 eyes, and PK in 4 eyes. Two patients were lost to follow-up. Five eyes of 4 patients referred to us within 10 days of symptom onset resolved on medical treatment with final visual acuity ranging from 20/20 to 20/80. CONCLUSIONS: In a tropical region, it is important to consider uncommon organisms such as fungi, Nocardia, and Acanthamoeba as possible etiological agents in keratitis after LASIK. A detailed microbiology work-up will help in definitive diagnosis and appropriate treatment.

Clinical, microbiological profile and treatment outcome of ocular infections caused by Achromobacter xylosoxidans.

PURPOSE: To study the microbiological profile and outcome of ocular infections caused by Achromobacter xylosoxidans. METHODS: Medical and microbiology records of patients with A. xylosoxidans ocular infections managed between May 2007 and December 2007 were reviewed. RESULTS: The authors identified 10 patients whose eyes were infected by A. xylosoxidans during the study period. Of 10 patients, 8 had microbial keratitis, of whom 6 developed an infection after penetrating keratoplasty. The remaining 2 patients had endophthalmitis. The Gram-stained smear did not reveal any organism in 6 of 10 cases. In the 4 remaining cases, Gram-negative bacilli were reported. Out of 10 isolates, 9 were sensitive to ceftazidime, 7 to amikacin, 5 to ciprofloxacin, and 3 to ofloxacin, gatifloxacin, and chloramphenicol. Only one isolate was sensitive to moxifloxacin. Of the 6 patients with graft infection, 2 patients were lost to follow-up, infection was resolved in 3 patients, and the infection remained active in 1 patient. The two patients with endophthalmitis responded to antibacterial therapy and showed improved visual acuity. Infection was resolved in 2 patients with keratitis. CONCLUSION: Although A. xylosoxidans ocular infections are rare, one should retain a high index of clinical suspicion in patients who present with slowly progressive disease characterized by a localized infiltration and show Gram-negative bacilli on smear examination.

Review of epidemiological features, microbiological diagnosis and treatment outcome of microbial keratitis: experience of over a decade.

PURPOSE: To review the epidemiological characteristics, microbiological profile, and treatment outcome of patients with suspected microbial keratitis. MATERIALS AND METHODS: Retrospective analysis of a non-comparative series from the database was done. All the patients presenting with corneal stromal infiltrate underwent standard microbiologic evaluation of their corneal scrapings, and smear and culture-guided antimicrobial therapy. RESULTS: Out of 5897 suspected cases of microbial keratitis 3563 (60.4%) were culture-proven (bacterial--1849, 51.9%; fungal--1360, 38.2%; Acanthamoeba--86, 2.4%; mixed--268, 7.5%). Patients with agriculture-based activities were at 1.33 times (CI 1.16-1.51) greater risk of developing microbial keratitis and patients with ocular trauma were 5.33 times (CI 6.41-6.44) more likely to develop microbial keratitis. Potassium hydroxide with calcofluor white was most sensitive for detecting fungi (90.6%) and Acanthamoeba (84.0%) in corneal scrapings, however, Gram stain had a low sensitivity of 56.6% in detection of bacteria. Majority of the bacterial infections were caused by Staphylococcus epidermidis (42.3%) and Fusarium species (36.6%) was the leading cause of fungal infections. A significantly larger number of patients (691/1360, 50.8%) with fungal keratitis required surgical intervention compared to bacterial (799/1849, 43.2%) and Acanthamoeba (15/86, 17.4%) keratitis. Corneal healed scar was achieved in 75.5%, 64.8%, and 90.0% of patients with bacterial, fungal, and Acanthamoeba keratitis respectively. CONCLUSIONS: While diagnostic and treatment modalities are well in place the final outcome is suboptimal in fungal keratitis. With more effective treatment available for bacterial and Acanthamoeba keratitis, the treatment of fungal keratitis is truly a challenge.

Post-operative endophthalmitis due to an unusual pathogen, Comamonas testosteroni.

Here, we describe the first report of post-operative endophthalmitis due to Comamonas testosteroni in an elderly diabetic patient after complicated cataract surgery. The isolate was identified by using Mini API strips. The patient was successfully treated with intravitreal ceftazidime and oral ciprofloxacin.

Comparison of clinical and microbiological profiles in smear-positive and smear-negative cases of suspected microbial keratitis.

PURPOSE: To examine the hypothesis that initial smear examination results have a significant bearing on the management and outcome of suspected microbial keratitis. MATERIALS AND METHODS: One hundred and seventy consecutive patients with suspected microbial keratitis were included in a prospective nonrandomized comparative study and their detailed clinical and microbiological data (smears and cultures of corneal scrapings) were captured on a predesigned corneal ulcer database. Patients were divided into two groups: Group 1 included 68 patients with corneal scrapings negative in smears while Group 2 included 102 patients with corneal scrapings positive in smears. The two groups were compared for their clinico-microbiological profile, management and clinical outcome. The outcome was noted at three months. Fisher's exact test was applied for statistical analysis. RESULTS: Cultures were sterile in 57.3% of patients in Group 1 compared to 17.6% in Group 2. Scrapings that grew S. pneumoniae, gram-negative organisms, fungi and Acanthamoeba were more often positive in smears (18.6%, 11.8%, 19.6% and 2.9% respectively). While data on duration of prior treatment was not available, prior medication made no significant difference to smear results. More (79.3%) patients of Group 1 had small infiltrate size ( CONCLUSIONS: Initial smear examination helps in instituting specific therapy thereby improving the outcome in cases of microbial keratitis. Positive smears indicate greater severity of disease and prior medication may not be a significant cause of smear negativity.

Is microsporidial keratitis an emerging cause of stromal keratitis? A case series study.

BACKGROUND: Microsporidial keratitis is a rare cause of stromal keratitis. We present a series of five cases of microsporidial keratitis from a single centre in southern India with microbiologic and histopathologic features. CASE PRESENTATION: Patient charts of five cases of microsporidial stromal keratitis diagnosed between January 2002 and June 2004 were reviewed retrospectively for clinical data, microbiologic and histopathologic data. The presence of microsporidia was confirmed by special stains on corneal scrapings and/or corneal tissues, and electron microscopy. All patients were immunocompetent with a preceding history of trauma in three. Four patients presented with unilateral, small, persisting deep stromal infiltrates, of uncertain etiology, in the cornea, which were not responding to conventional antimicrobial treatment and required penetrating keratoplasty in three. Fifth case was unsuspected and underwent keratoplasty for post-traumatic scar. Three of five cases were diagnosed on corneal scrapings, prior to keratoplasty, while two were diagnosed only on histology. The microsporidia appeared as oval well defined bodies with dense staining at one pole. None of the patients showed recurrence following keratoplasty. CONCLUSION: Microsporidia, though rare, should be suspected in chronic culture-negative stromal keratitis. Organisms could lie dormant without associated inflammation.

Relationship between clinical presentation and visual outcome in postoperative and posttraumatic endophthalmitis in south central India.

PURPOSE: To determine risk factors for poor visual outcome in postoperative and posttraumatic endophthalmitis in a large referral center in south central India. METHODS: In this prospective observational series the authors examined 388 patients of postoperative (n= 206) and posttraumatic (n= 182) endophthalmitis at the L V Prasad Eye Institute in Hyderabad, India between 1991 and 1997. The analysis was confined to 236 patients-128 (62.1%) postoperative and 108 (59.3%) posttraumatic patients who were followed for a minimum period of 3 months. A detailed protocol was followed. Chi-square and logistic regression analysis were used to determine risk factors for visual outcome worse than 6/18 and worse than 6/120. RESULTS: Postoperative endophthalmitis: In univariate analysis the features associated with poor visual acuity (grouped as < 6/18 and < 6/120) included intracapsular cataract surgery, poor presenting visual acuity, presence of vitreous cells, inability to visualise the optic disc on indirect ophthalmoscopy, presence of vitreous membranes on ultrasonography, and a culture-positive vitreous biopsy. In the multivariate analysis, visual acuity of less or equal light perception (LP) at presentation was associated with a 3-month postoperative visual acuity of < 6/18, with an odds ratio of 5.85 [1.25 - 27.42, 95% CI], and vitreous membranes seen on ultrasonography was associated with a final visual acuity of < 6/120, with an odds ratio of 2.47 [1.05 - 5.83, 95% CI]. Posttraumatic endophthalmitis: In univariate analysis the features associated with poor visual acuity (grouped as < 6/18 and < 6/120) included a retained intraocular foreign body (IOFB), trauma by needle (hypodermic or sewing), poor presenting visual acuity, inability to visualise the optic disc on indirect ophthalmoscopy, presence of vitreous membranes on ultrasonography, and a culture-positive vitreous biopsy. In multivariate analysis, IOFB was associated with a 3-month follow-up visual acuity of < 6/18, with an odds ratio of 5.90 [1.85 - 18.78, 95% CI], and trauma by a needle (hypodermic or sewing) and retained IOFB was associated with a final visual acuity of < 6/120, with an odds ratio of 4.47 [1.22 - 16.38, 95%CI] and 3.76 [1.36 - 10.37, 95% CI] respectively. CONCLUSION: This is the largest, single-centre, prospective study on risk factors for poor visual outcome in postoperative and posttraumatic endophthalmitis. The independent risk factor for 3-month follow-up visual acuity of < 6/18 was the presenting visual acuity of < or =LP in postoperative endophthalmitis and a retained IOFB in posttraumatic endophthalmitis. The independent risk factor for 3-month visual acuity of < 6/120 was the presence of vitreous membranes on ultrasonography in postoperative endophthalmitis, and trauma by a needle (hypodermic/ sewing) and retained IOFB in posttraumatic endophthalmitis.

Ophthalmic applications of preserved human amniotic membrane: a review of current indications.

Preserved human amniotic membrane (AM) is currently being used for a wide spectrum of ocular surface disorders. The AM has a basement membrane, which promotes epithelial cell migration and adhesion. The presence of a unique avascular stromal matrix reduces inflammation, neovascularization and fibrosis. The basic tenets of amniotic membrane transplantation (AMT) are to promote re-epithelialization, to reconstruct the ocular surface and to provide symptomatic relief from surface aberrations. AMT is a useful technique for reconstruction of surface defects resulting from removal of surface tumors and symblephara. AMT has effectively restored a stable corneal epithelium in eyes with, persistent epithelial defects and corneal ulcers. In the setting of acute ocular burns and SJS, AMT has satisfactorily reduced scarring and inflammation. AMT alone may be an effective alternative for partial limbal stem cell deficiency. However remarkable improvements in surface stability have resulted from concurrent AMT and limbal stem cell transplantation, wherein the limbal grafts are obtained from the normal fellow eye, living relative or cadaveric eye. In severe or bilateral cases, well being of the donor eye is a major concern. Currently, the most unique application of preserved human AM in ophthalmology is its use as a substrate for ex-vivo expansion of corneal and conjunctival epithelium. In this novel technique of tissue engineering, epithelial stem cells can be safely harvested and expanded on denuded AM. The resultant composite cultured tissue has been successfully transplanted to restore vision, as well as the structure and function of damaged ocular surfaces.

Pigmented plaque presentation of dematiaceous fungal keratitis: a clinicopathologic correlation.

PURPOSE: To evaluate the clinical, microbiologic, and histopathologic features of dematiaceous fungal keratitis cases presenting with pigmented, raised, plaque-like infiltrate. STUDY DESIGN: Consecutive case series. METHODS: Microbiology-proven cases of fungal keratitis presenting with a pigmented infiltrate were included in the study. A detailed clinical and microbiological evaluation was performed in all cases. The lesion was removed by superficial keratectomy, and the specimen was subjected to histopathologic examination. Patients presenting with a large infiltrate had penetrating keratoplasty, and the corneal button was submitted for histopathology examination. RESULTS: We enrolled 15 cases in the study. There were 11 men and 4 women. The mean age of the patients was 48.5 years (range 27-68 years). The patients presented to us with duration of symptoms ranging from 7 to 60 days (mean 27.6 +/- 15.6, median 30). The visual acuity was better than 20/200 in 9 (60%) cases. The infiltrate size varied from 4.3 to 64 mm2 (mean 26.9 +/- 16.6, median 22.5). Ten (66.7%) cases had a central infiltrate. The infiltrate was dry and raised, with brown to black pigmentation on its surface. Corneal scrapings revealed septate fungal filaments in all cases and the characteristic brown to black pigmentation of the fungal cell wall in 10 (66.7%) cases. Although there was a significant growth of dematiaceous fungi on culture in all cases, species identification could be done in 3 cases only. Examination of tissue sections revealed a carpet of pigmented fungal filaments on the corneal surface (n = 12, 92.3%) associated with mild to moderate inflammation (n = 11, 84.7%) and tissue destruction. Nine out of 11 cases that had keratectomy resolved with medical therapy. CONCLUSIONS: The pigmented plaque-like infiltrate in dematiaceous fungal keratitis consists of surface colonization of pigmented fungal filaments associated with mild to moderate inflammation and tissue destruction of the underlying corneal stroma.

Fungal infection of sutureless self-sealing incision for cataract surgery.

PURPOSE: To report the clinical picture and outcome of fungal infection of self-sealing wounds in cataract surgery. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Seven postoperative cataract patients. METHODS: Seven consecutive patients who underwent cataract surgery in different locations in India and developed microbiologically proven fungal infection of the surgical wound were included. All were managed at a tertiary eye care center in India between May 2001 and April 2002. MAIN OUTCOME MEASURES: The data reviewed included patient age, gender, onset of symptoms after surgery, examination findings at the time of onset of symptoms and referral, laboratory workup, treatment, and outcome. The cataract surgeons involved were contacted to determine their cataract practice and to determine any possible breach in the sterile technique. RESULTS: The median interval to onset of symptoms after cataract surgery was 5.0 days (mean, 5.8 days; range, 3-9 days). The initial diagnoses at the time of onset of symptoms were keratitis (n = 3), scleritis (n = 1), and excessive anterior chamber reaction (n = 3). The last 4 patients were treated with topical and/or systemic corticosteroid therapy before referral. All cases subsequently developed deep keratitis. Specimens for microbiology workup were obtained by scrapings (n = 6), corneoscleral biopsy (n = 4), and anterior chamber paracentesis (n = 4). Organisms identified were Aspergillus flavus (n = 2), Aspergillus terreus (n = 2), Aspergillus spp. (n = 2), and Candida albicans (n = 1). The infection resolved with medical therapy in 2 cases; the final visual acuity was 20/125 in one case and 20/20 in the other case. The infection progressed to endophthalmitis in 5 eyes, resulting in complete loss of vision. The source of infection could not be identified in any case. CONCLUSIONS: Infection of self-sealing tunnel incision for cataract surgery is a diagnostic and therapeutic challenge.

Clinical experience with N-butyl cyanoacrylate tissue adhesive in fungal keratitis.

PURPOSE: To evaluate the role of tissue adhesive in the management of corneal thinning or perforation associated with active fungal keratitis. DESIGN: Retrospective noncomparative interventional case series. METHODS: Seventy-three eyes of 73 patients with microbiologically proven keratomycosis associated with thinning or perforation participated in the study. N-Butyl cyanoacrylate tissue adhesive (medical grade) and bandage contact lens were applied in addition to topical and systemic antifungal therapy. Our outcome measures included resolution of the infiltrate and preservation of the structural integrity of the globe. RESULTS: Outcome data were available for 66 eyes. The infiltrate resolved with scar formation in 42 (63.6%) eyes. In an additional eight (12.1%) eyes, tissue adhesive maintained the structural integrity of the globe while the patients awaited penetrating keratoplasty. Sixteen (24.2%) eyes showed progressive worsening or persistence of the infiltrate after application of tissue adhesive. Twenty-five (37.8%) eyes required multiple applications of tissue adhesive. The outcome was better in cases where the infiltrate measured less than 30 mm2 at the time of presentation and application of tissue adhesive (P < 0.01). CONCLUSION: In view of the poor outcome of penetrating keratoplasty in active fungal keratitis, N-butyl cyanoacrylate tissue adhesive is a useful modality for the management of progressive thinning or perforation associated with active fungal keratitis. However, close observation is mandatory to assess the progression of disease.

Fungal keratitis associated with vernal keratoconjunctivitis.

PURPOSE: To report a case of fungal keratitis associated with vernal keratoconjunctivitis. CASE REPORT: A 22-year-old man with a history of vernal keratoconjunctivitis since October 1999 developed a shield ulcer in the left eye in June 2000, which resolved with intensive topical steroid therapy. He presented in August 2001 with onset of acute pain, redness, and decreased vision. The tarsal conjunctiva in the left eye showed large papillae. The cornea showed a white plaque-like lesion with an underlying stromal infiltrate involving the upper half of the cornea. The overlying epithelial defect measured 4.5 x 2.5 mm. The anterior chamber showed 1+ flare and cells and hypopyon measuring about 1 mm. RESULTS: Corneal scrapings were performed for microbiologic investigations. Smears of corneal scrapings revealed septate fungal filaments, and the culture showed a significant growth of Aspergillus flavus. CONCLUSIONS: Fungal keratitis may be associated with vernal keratoconjunctivitis. Though rare, fungal keratitis should be considered in the differential diagnosis of infections associated with vernal keratoconjunctivitis.