Locality is the strongest predictor of expert performance in image-based differentiation of bacterial and fungal corneal ulcers from India.

PURPOSE: This study sought to identify the sources of differential performance and misclassification error among local (Indian) and external (non-Indian) corneal specialists in identifying bacterial and fungal keratitis based on corneal photography. METHODS: This study is a secondary analysis of survey data assessing the ability of corneal specialists to identify acute bacterial versus fungal keratitis by using corneal photography. One-hundred images of 100 eyes from 100 patients with acute bacterial or fungal keratitis in South India were previously presented to an international cohort of cornea specialists for interpretation over the span of April to July 2021. Each expert provided a predicted probability that the ulcer was either bacterial or fungal. Using these data, we performed multivariable linear regression to identify factors predictive of expert performance, accounting for primary practice location and surrogate measures to infer local fungal ulcer prevalence, including locality, latitude, and dew point. In addition, Brier score decomposition was used to determine experts' reliability ("calibration") and resolution ("boldness") and were compared between local (Indian) and external (non-Indian) experts. RESULTS: Sixty-six experts from 16 countries participated. Indian practice location was the only independently significant predictor of performance in multivariable linear regression. Resolution among Indian experts was significantly better (0.08) than among non-Indian experts (0.01; P < 0.001), indicating greater confidence in their predictions. There was no significant difference in reliability between the two groups ( P = 0.40). CONCLUSION: Local cornea experts outperformed their international counterparts independent of regional variability in tropical risk factors for fungal keratitis. This may be explained by regional characteristics of infectious ulcers with which local corneal specialists are familiar.

Preliminary observations on tear film interferometry performed in horses.

This retrospective study evaluated tear film (TF) interferometry on horses examined in Northern Italy in 2019-2021. The objectives were to evaluate horses affected by keratitis, and to describe TF values in horses with no evidence of ocular disease. All horses received a complete ophthalmic examination and were examined with the Ocular Surface Analyser, Veterinary-setting, prior to eye manipulation, staining and sample collection. Eighteen horses with no evidence of ocular disease were included in the comparison group. Additionally, 46 horses displaying signs of keratitis (neovascularization, corneal opacities, ulceration, epithelial and subepithelial infiltrates) were evaluated. These horses were divided into presumed non-infectious and infectious or presumed infectious keratitis groups (one with proven bacterial origin, and the others with diagnosed or presumptive keratomycosis) with the former including immune-mediated keratitis. From the observations of TF interferometry in the comparison population the authors concluded that for non-invasive break-up time (NIBUT), the estimated preliminary reference interval was 10.4-31.2s, and for tear meniscus height (TMH), it was 0.215-0.457mm. Moreover, within the keratitis population, from an interferometric point of view punctate lesions of the ocular surface were present in all cases of active diagnosed or presumptive subepithelial keratomycosis but not in any of the non-infectious cases, either non-ulcerative or ulcerative. Limitations of the study include a relatively low number of horses examined and the fact that the diagnosis of infectious keratitis was presumptive and based on clinical improvement after treatment in some cases. To the authors' knowledge, this is the first report of TF interferometry performed in horses.

Demographic and microbiological profile of corneal ulcer patients presenting at a tertiary healthcare center of Eastern India during the COVID era: A hospital-based cross-sectional study.

Purpose: To determine the demographic and microbiological profile involved in the causation of corneal ulcers in Eastern India during the COVID era. Method: Patients presenting with corneal ulcers fulfilling the inclusion and exclusion criteria were taken as the case. The study duration was from January 2021 to December 2021. Socio-demographic details and information about risk factors were noted. A detailed corneal examination followed by corneal scraping was performed for microbiological evaluation. Results: In 1 year, 99 infective corneal ulcer patients were evaluated. Farmers (24.2%) were found to be maximally affected by corneal ulcers. The peak in cases was recorded from October to December (38.4%). Ocular trauma was the commonest risk factor (42.4%). The majority (80.8%) of patients were already on some topical antimicrobials. 22.2% of samples showed fungal filaments on KOH mount; 54.5% of these cases turned out to be culture-positive. 17.56% of KOH-negative samples turned out to be culture-positive (fungal). Overall, the culture positivity rate was 28.28% out of which fungal isolates were 89.28% and bacterial isolates were 10.72%. Fusarium species were identified as the most common organism contributing 42.85%, followed by Aspergillus fumigatus (14.28%). 10.72% of cases were culture positive for Pseudomonas aeuroginosa. Conclusion: Trauma with the organic matter was the predominant cause of fungal keratitis. In this study, fungal keratitis was found to be more common. Fusarium was the most common isolate.

Microbial keratitis in Sao Paulo, Brazil: a 10-year review of laboratory results, epidemiological features, and risk factors.

PURPOSE: To study epidemiological data, laboratory results, and risk factors associated with microbial keratitis. METHODS: We conducted a retrospective study of corneal sample cultures from patients with microbial keratitis from January 2010 to December 2019. Results were analyzed according to the etiological diagnosis of bacterial, mycotic, or parasitic infection and were associated with related risk factors. RESULTS: We analyzed 4810 corneal samples from 4047 patients (mean age 47.79 ± 20.68 years; male 53.27%). The prevalence of bacterial, fungal, and Acanthamoeba infections were 69.80%, 7.31%, and 3.51%, respectively. The most frequently isolated bacteria were coagulase-negative Staphylococcus (CoNS) (45.14%), S. aureus (10.02%), Pseudomonas spp. (8.80%), and Corynebacterium spp. (6.21%). Among CoNS, the main agent was S. epidermidis (n=665). For mycotic keratitis, Fusarium spp. (35.42%) and Candida parapsilosis (16.07%) were the most common agents among filamentous and yeasts isolates, respectively. Contact lens use was associated with a positive culture for Acanthamoeba spp. (OR = 19.04; p < 0.001) and Pseudomonas spp. (OR = 3.20; p < 0.001). Previous ocular trauma was associated with positive fungal cultures (OR = 1.80; p = 0.007), while older age was associated with positive bacterial culture (OR = 1.76; p = 0.001). CONCLUSIONS: Our findings demonstrated a higher positivity of corneal sample cultures for bacteria. Among those, CoNS was the most frequently identified, with S. epidermidis as the main agent. In fungal keratitis, Fusarium spp. was the most commonly isolated. Contact lens wearers had higher risks of positive cultures for Acanthamoeba spp. and Pseudomonas spp. Ocular trauma increased the risk of fungal infection, while older age increased the risk of bacterial infection.

Ocular candidiasis in a tertiary hospital in Japan: A 10-year single-center retrospective study.

Ocular candidiasis is a major complication of candidemia that is sometimes sight-threatening. Although prompt ophthalmologic consultation and antifungal medication have been emphasized, recent changes in the causative species and drug susceptibilities make the picture unclear. This study aimed to determine whether there are trends among patients with ocular candidiasis and included 80 patients with candidemia who underwent ophthalmological screening at our hospital between 2010 and 2020. Data on the clinical characteristics, comorbidities, biochemical test results, causative Candida species, treatment, outcomes, visual acuity, and antifungal susceptibility were collected and analyzed. Statistical analyses were performed by comparing two groups, namely, the ocular candidiasis (n = 29) and non-ocular candidiasis (n = 51) groups. In the ocular candidiasis group, there were significantly more cases of central venous catheter insertion (82.8%, p = 0.026) and Candida albicans candidemia (72.4%, p < 0.001). Regarding ocular involvement, the majority of patients were asymptomatic. Most cases improved with antifungal therapy, but one case underwent vitrectomy. Between 2016 and 2020, there was a diversification of species, with a decrease in Candida parapsilosis and the emergence of Candida glabrata and Candida tropicalis. Regarding drug susceptibility, the minimum inhibitory concentrations of echinocandin and 5-fluorocytosine against Candida albicans, Candida parapsilosis, and Candida glabrata were slightly increased. In conclusion, in addition to appropriately performing ophthalmologic examinations, it is beneficial to select antifungal agents according to the diversity of species and drug susceptibilities.

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.

Prevalence of Ocular Candidiasis and Candida Endophthalmitis in Patients With Candidemia: A Systematic Review and Meta-Analysis.

BACKGROUND: Infectious diseases and ophthalmology professional societies have disagreed regarding ocular screening in patients with candidemia. We aimed to summarize the current evidence on the prevalence of ocular candidiasis (OC) and Candida endophthalmitis (CE) according to the standardized definitions. METHODS: A literature search was conducted from the inception date through 16 October 2022 using PubMed, Embase, and SCOPUS. Pooled prevalence of ocular complications was derived from generalized linear mixed models (PROSPERO CRD42022326610). RESULTS: A total of 70 and 35 studies were included in the meta-analysis for OC and concordant CE (chorioretinitis with vitreous involvement), respectively. This study represented 8599 patients with candidemia who underwent ophthalmologic examination. Pooled prevalences (95% CI) of OC, overall CE, concordant CE, and discordant CE were 10.7% (8.4-13.5%), 3.1% (2.1-4.5%), 1.8% (1.3-2.6%), and 7.4% (4.5-12%) of patients screened, respectively. Studies from Asian countries had significantly higher concordant CE prevalence (95% CI) of patients screened (3.6%; 2.9-4.6%) compared with studies from European countries (1.4%; .4-5%) and American countries (1.4%; .9-2.2%) (P <.01). Presence of total parenteral nutrition and Candida albicans was associated with CE, with pooled odds ratios (95% CI) of 6.92 (3.58-13.36) and 3.02 (1.67-5.46), respectively. CONCLUSIONS: Prevalence of concordant CE overall and among Asian countries was 2 and 4 times higher than the prevalence previously reported by the American Academy of Ophthalmology (AAO) of <0.9%, respectively. There is an urgent need to study optimal screening protocols and to establish joint recommendations by the Infectious Diseases Society of America and AAO.

Fungal Infection After Descemet Membrane Endothelial Keratoplasty: Incidence and Outcomes.

PURPOSE: The aim of the study was to describe the incidence, presentation, management, and outcomes of fungal infection after Descemet membrane endothelial keratoplasty (DMEK). METHODS: Retrospective case series of culture-proven fungal infections after DMEK reported in the literature, directly by surgeons, and to the Eye Bank Association of America from January 1, 2011, to December 31, 2020. RESULTS: The domestic incidence of fungal infections, fungal keratitis, and fungal endophthalmitis after DMEK from 2011 to 2020 was 3.5, 1.3, and 2.2 per 10,000 cases, respectively, with no significant increasing trend. Thirty-four cases were identified, 14 (41.2%) published and 20 (58.8%) unpublished. Donor tissue fungal cultures were performed in 20 of the 34 (58.8%) cases and were positive in 19 of the 20 (95.0%), all but one Candida species. Recipient fungal cultures were performed in 29 of the 34 (85.3%) cases and were positive in 26 of the 29 (89.7%), all but one Candida species. Infection presented a mean of 33 ± 38 days (median 23, range 2-200, outlier 949) after transplantation: 25 (73.5%) with endophthalmitis and 9 (26.5%) with keratitis. Topical, intrastromal, intracameral, intravitreal, or systemic antifungal therapy was used in all 27 eyes with treatment data. Surgical intervention (DMEK explantation or partial removal, repeat endothelial keratoplasty, penetrating keratoplasty, and/or pars plana vitrectomy) was required in 21 of the 27 (77.8%) eyes. The corrected distance visual acuity at the last follow-up was ≥20/40 in 13 of the 27 (48.1%) eyes and counting fingers or worse in 6 of the 27 (22.2%) eyes. CONCLUSIONS: Fungal infection is a rare but serious complication of DMEK that results in counting fingers or worse corrected distance visual acuity in nearly a quarter of eyes.

An Outbreak of Fungal Endophthalmitis After Cataract Surgery in South Korea.

Importance: Fungal endophthalmitis caused by contaminated medical products is extremely rare; it follows an intractable clinical course with a poor visual prognosis. Objective: To report the epidemiologic and clinical features and treatment outcomes of a nationwide fungal endophthalmitis outbreak after cataract surgery as a result of contaminated viscoelastic agents in South Korea. Design, Setting, and Participants: This was a retrospective case series analysis of clinical data from multiple institutions in South Korea conducted from September 1, 2020, to October 31, 2021. Data were collected through nationwide surveys in May and October 2021 from the 100 members of the Korean Retinal Society. Patients were diagnosed with fungal endophthalmitis resulting from the use of the viscoelastic material sodium hyaluronate (Unial [Unimed Pharmaceutical Inc]). Data were analyzed from November 1, 2021, to May 30, 2022. Main Outcomes and Measures: The clinical features and causative species were identified, and treatment outcomes were analyzed for patients who underwent 6 months of follow-up. Results: The fungal endophthalmitis outbreak developed between September 1, 2020, and June 30, 2021, and peaked in November 2020. An official investigation by the Korea Disease Control and Prevention Agency confirmed contamination of viscoelastic material. All 281 eyes of 265 patients (mean [SD] age, 65.4 [10.8] years; 153 female individuals [57.7%]) were diagnosed with fungal endophthalmitis, based on clinical examinations and supportive culture results. The mean (SD) time period between cataract surgery and diagnosis was 24.7 (17.3) days. Patients exhibited characteristic clinical features of fungal endophthalmitis, including vitreous opacity (212 of 281 [75.4%]), infiltration into the intraocular lens (143 of 281 [50.9%]), and ciliary infiltration (55 of 281 [19.6%]). Cultures were performed in 260 eyes, and fungal presence was confirmed in 103 eyes (39.6%). Among them, Fusarium species were identified in 89 eyes (86.4%). Among the 228 eyes included in the treatment outcome analysis, the mean (SD) best-corrected visual acuity improved from 0.78 (0.74) logMAR (Snellen equivalent, 20/120 [7.3 lines]) to 0.36 (0.49) logMAR (Snellen equivalent, 20/45 [4.9 lines]) at 6 months. Furthermore, disease remission with no signs of fungal endophthalmitis (or cells in the anterior chamber milder than grade 1) was noted in 214 eyes (93.9%). Conclusions and Relevance: This was a retrospectively reviewed case series of a fungal endophthalmitis outbreak resulting from contaminated viscoelastic material. Findings of this case series study support the potential benefit of prompt, aggressive surgical intervention that may reduce treatment burden and improve prognosis of fungal endophthalmitis caused by contaminated medical products.

Evaluation of Vitreous Galactomannan and (1, 3) ß-D-Glucan Levels in the Diagnosis of Fungal Endophthalmitis in Southern India.

PURPOSE: To evaluate vitreous Galactomannan(GM) and 1,3 ß-D-Glucan (BDG) levels in the diagnosis of fungal endophthalmitis, with emphasis on culture-negative cases. METHODS: Vitreous from 31 clinically suspected fungal endophthalmitis patients and 11 controls were evaluated for GM and BDG using ELISA Kits. The Receiver Operating Characteristic (ROC) curves and diagnostic significance was calculated. RESULTS: The median vitreous GM in culture-positive (60.83pg/ml) and culture-negative (59.9pg/ml) samples were higher than the (51.2pg/ml) control group. The median vitreous BDG in culture-positive (1.47pg/ml) and culture-negative (1.52pg/ml) samples were also similar, and higher than the control group (1.18pg/ml). ROC analysis showed that at a cut-off of 51.35pg/ml, the sensitivity and specificity for GM were 0.88 and 0.73.Similarly, for BDG at a cut-off of 1.18pg/ml, the sensitivity and specificity were 0.94 and 0.82 respectively. CONCLUSION: Vitreous GM and BDG above the indicated threshold level could suggest a fungal infection, even when cultures are negative.

The microbiological landscape and epidemiology of ocular infections in a multi-tier ophthalmology network in India: an electronic medical record driven analytics report.

OBJECTIVE: To study the epidemiology and landscape of ocular infections in patients undergoing microbiological investigations across a multi-tier ophthalmology network in India. METHODS: This cross-sectional hospital-based study included 15,822 patients in whom microbiology samples were analysed between September 2013 and December 2021. Ocular tissue of patients in whom a microbiology sample was processed in at least one eye were included. The data were collected using an indigenously developed electronic medical record system. RESULTS: Among the 15,822 patients, bacteria (51.06%) was the most common aetiology followed by fungus (38.27%). The majority of the patients were male (68.10%) and adults (90.01%). The most common age group was during the sixth decade of life with 2,914 (18.42%) patients. The patients were more commonly from the lower socio-economic status (51.61%) and from the rural geography (46.82%). Majority of the specimens sent for microbiological analysis were corneal scrapings (68.61%) followed by vitreous (8.77%). The most common bacteria isolated was Staphylococcus aureus (14.45%) followed by Pseudomonas aeruginosa (12.53%) and among the fungus were Fusarium (30.53%) and Aspergillus species (29.86%). Acanthamoeba (1.26%) and Microsporidia (0.38%) accounted for a minority of the infections in the samples. Fungus (53.10%; p ≤ 0.00001) and virus (51.08%; p = 0.000673) aetiology was found to be significantly higher in patients presenting from the rural geography. CONCLUSION: The most common aetiology of infection in ocular disease is bacterial but fungal infections also accounted for a significant proportion. The majority of the patients with ocular infections presented from the rural geography and from lower socio-economic status.

Trends of ocular fungal infections in North China (2001-2020).

OBJECTIVES: To analyze the epidemiologic features, culture positivity, the fungal spectrum of different sites of ocular infection in North China over 20 years from 2001 to 2020. METHODS: 11, 635 patients suspected of ocular fungal infection were reviewed. The demographic profile, fungal positive culture rate among different sites, the distribution, and trends of main pathogens among cornea and intraocular fluid were analyzed. RESULTS: Among 11, 635 samples, the positive culture rate of ocular fungal infection was 23.6%. Most of samples (83.1%) were from cornea, and their culture positivity was 26.9%. Fungal keratitis occurred more often during the harvesting season (October to December; 34.0%) than in other seasons (average: 22.0%). Fusarium sp. (53.2%), Aspergillus sp. (15.9%) and Alternaria sp. (12.5%) were the most common fungal species of ocular mycotic infections in the past two decades in north China. 2562 organisms were identified from cornea, of which 1443 (56.3%) were Fusarium sp., 403 (15.7%) and 329 (12.8%) were Aspergillus sp., and Alternaria sp., respectively. Of the 120 fungi isolated from the intraocular fluid, the most common was Aspergillus sp. (33.3%), followed by Fusarium sp. (24.2%) and Candida sp. (15.0%). CONCLUSIONS: Fusarium sp., Aspergillus sp. and Alternaria sp. were the most common organisms in cases of fungal keratitis, while Aspergillus sp., Fusarium sp. and Candida sp. were the most frequent isolates for fungal endophthalmitis.

Positive Microbiological Culture among Patients with Infective Keratitis Visiting the Cornea Unit of a Tertiary Care Centre.

Introduction: Keratitis is the infection and inflammation of the cornea. Microbial keratitis is a potentially sight-threatening corneal condition. The aim of this study was to find out the prevalence of positive microbiological culture among patients with infective keratitis visiting the Cornea Unit of a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients with a clinical diagnosis of infective keratitis presenting to the Cornea Unit of a tertiary eye care centre from 16 October 2020 to 16 March 2021 after obtaining ethical approval from the Ethical Review Board. After slit-lamp examination, corneal scrapings were performed under aseptic conditions which were subjected to Gram stain, potassium hydroxide preparation and culture for bacterial and fungal pathogens. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 428 patients, 337 (78.73%) (73.24-84.33, 95% Confidence Interval) had a positive microbiological culture. A total of 213 (49.76%) of enrolled samples had a prior history of ocular trauma. Aspergillus species 68 (20.17%) and Streptococcus species 33 (9.79%) were the most common organisms isolated from fungal and bacterial corneal ulcers respectively. Conclusions: The prevalence of positive microbiological culture among patients with infective keratitis from this study is similar to the pattern reported from similar settings. Keywords: corneal ulcer; keratitis; prevalence.

Evaluation of antifungal susceptibility and clinical characteristics in fungal keratitis in a tertiary care center in North India.

Purpose: To study the antifungal susceptibility of common corneal pathogenic fungi to antifungal agents in the North Indian population. Methods: Prospective study of the antifungal sensitivity testing (natamycin, amphotericin B, voriconazole, itraconazole, fluconazole, posaconazole, caspofungin, micafungin) of fungal isolates from 50 cases of culture positive fungal keratitis by using E test method. Details noted included demographic data, visual acuity, clinical details, grade of keratitis, healing time, and success in medical management. Results: Of 50 patients with fungal keratitis (mean age: 40.28 ± 16.77 years), 12 eyes healed within 3 weeks, 14 had a delayed healing response, and 24 had chronic keratitis. Among the 15 cases of Fusarium isolates, 93.3% were sensitive to natamycin, while 40% to amphotericin B; 66.6% to voriconazole, 13.4% to itraconazole and fluconazole each. 80% of Fusarium cases (n = 12) showed susceptibility to posaconazole. Among Aspergillus flavus isolates, 53.4% (n = 8) were sensitive to natamycin, with only 40% (n = 7) showing sensitivity to amphotericin B and good susceptibility to azoles. MIC against susceptible Fusarium spp. for natamycin was 3-16 µg/mL, amphotericin B: 1-8 µg/mL, voriconazole: 0.5-1.5 µg/mL, itraconazole: 0.5-12 µg/mL, posaconazole: 0.094-1.5 µg/mL. MIC against Aspergillus flavus was natamycin: 8-32 µg/mL, amphotericin B: 0.5-16 µg/mL, voriconazole: 0.025-4 µg/mL, itraconazole: 0.125-8 µg/mL, posaconazole: 0.047-0.25 µg/mL; against Aspergillus niger isolates, to natamycin was 6 µg/mL (n=1), amphotericin B 8-12 µg/mL (n = 3), voriconazole: 0.125-0.19 µg/mL (n = 3), itraconazole: 0.38-0.75 µg/mL, posaconazole: 0.064-0.19 µg/mL and against Aspergillus fumigatus (n = 1), was natamycin4 µg/mL, amphotericin B - 8 µg/mL, voriconazole 0.25 µg/mL, itraconazole 1 µg/mL, and posaconazole 0.19 µg/mL. MIC against susceptible Acremonium spp. for natamycin was 1.5-16 µg/mL, amphotericin B: 0.5-8 µg/mL, voriconazole: 0.19-3 µg/mL, itraconazole: 0.125 µg/mL, posaconazole: 0.125-0.5 µg/mL and against susceptible Curvularia was natamycin 0.75-4 µg/mL, amphotericin B 0.5-1 µg/mL, voriconazole 0.125-0.19 µg/mL, itraconazole 0.047-0.094 µg/mL, posaconazole 0.047-0.094 µg/mL. MIC against Mucor spp.+ Rhizopus spp. (n = 1) was natamycin: 8 µg/mL, amphotericin B: 0.75 µg/mL, posaconazole: 1.5 µg/mL. MIC against of Alternaria (n = 1) was voriconazole: 0.19 µg/mL, posaconazole: 0.094 µg/mL. MIC against Penicillium (n=1) was natamycin: 8 µg/mL, voriconazole: 0.25 µg/mL, itraconazole: 0.5 µg/mL, and Posaconazole: 0.125 µg/mL. Conclusion: Our observations highlight the variations in susceptibility to antifungal agents. Posaconazole seems to be effective with low MIC against common corneal pathogenic fungal isolates.

Molecular characterization of fungal endophthalmitis and keratitis caused by yeasts.

Candida species are the most common causes of sight-threatening fungal ocular infections in temperate regions of the world. Despite their relevance, little is known about the emergence of novel species and the molecular epidemiology of these infections. Here, we molecularly characterized 38 yeast isolates collected from patients diagnosed with endophthalmitis or keratitis at Massachusetts Eye and Ear from 2014 to 2021. Sequencing of the ITS1-5.8S-/ITS2 regions demonstrated that this population of yeasts was dominated by Candida spp. (37 out of 38; 97%), with 58% of the cases caused by C. albicans (n = 22) and the remaining by emerging non-albicans species, predominantly by C. parapsilosis (n = 8) and C. dubliniensis (n = 6). One isolate each was identified as C. tropicalis and Clavispora lusitaniae. Interestingly, all C. dubliniensis were isolated from endophthalmitis and most C. parapsilosis from keratitis. Multilocus sequence typing analysis of C. albicans showed a prevalence of CC-1 isolates that has DST69 as the putative founder, with 64% of them belonging to this clonal complex (CC). Isolates grouped within this cluster were more predominant in endophthalmitis (10 out of 14; 71%). One C. albicans CC-1 isolate was multi-azole resistant. In conclusion, we observed that nearly half of the ocular infections caused by yeasts are associated with C. albicans, with evidence for the emergence of non-albicans species that are differentially enriched in distinct ocular niches. Candida albicans isolates clustered within the predominant CC-1 group were particularly more common in endophthalmitis, demonstrating a potential pattern of ocular disease enrichment within this clade.

Candida species are the most common pathogen responsible for ocular infections in the temperature regions of the world. Here, we sequenced and molecularly characterized the Candida species seen in patients who present to our hospital with infection to understand the species' distribution over time.

Fungal Endophthalmitis Outbreak after Cataract Surgery, South Korea, 2020.

In November 2020, an unusual increase in fungal endophthalmitis cases after cataract surgery was reported to the Korea Disease Control and Prevention Agency, South Korea. We initiated an outbreak investigation to identify the cause. We identified 156 cases nationwide, 62 confirmed and 94 probable. Most case-patients were exposed during surgery to ocular viscoelastic devices (OVDs) from the same manufacturer (company A). We isolated Fusarium spp. from 50 confirmed cases. Molecular identification of 39 fungal isolates from clinical samples and 13 isolates from OVDs confirmed F. oxysporum caused the infections. The risk ratio for fungal endophthalmitis from company A's OVDs was 86.0 (95% CI 27.4-256.9), much higher than risk from other manufacturers' products. We determined this fungal endophthalmitis outbreak was caused by a contaminated lot of OVDs and recommended discontinued use of this product. Early recognition of outbreaks and joint responses from related government agencies can reduce risk for fungal endophthalmitis.

Acremonium keratitis: Risk factors, clinical characteristics, management, and outcome in 65 cases.

Purpose: To study the risk factors, clinical presentation, management options, and outcomes in cases of culture-proven Acremonium keratitis. Methods: Medical and microbiology records of culture-proven Acremonium keratitis from Jan 2007 to Dec 2019 at a tertiary eye care center were reviewed. Details of clinical findings on each visit and operating notes were reviewed from the medical records. All cases were subjected to corneal scraping at the first visit for microbiological investigation consisting of direct smear examination and culture. Topical natamycin 5% was the mainstay of medical treatment. Surgical treatment was considered for nonresponding patients. Results: During the 13-year study period, 65 cases of culture-proven Acremonium keratitis were identified out of 1605 cases of fungal keratitis. Trauma was the most common predisposing factor in 32 cases (49.2%). The average area of the corneal stromal infiltrate was 24.8 mm2 at the initial presentation. Hypopyon at the time of presentation was evident in 28 (43.1%) cases. Staphylococcus spp. was the most common (n = 22, 33.8%) organism coexistent with Acremonium. Direct microscopy of corneal scraping was positive for fungal filaments in 57/65 (87.6%) cases. Medical management alone was given in 44 patients (67.6%). Age (>50 years) and treatment delay (>15 days) were found to be independent risk factors for the poor final visual outcome (VA <20/60). Conclusion: When treated early, Acremonium keratitis responds well to medical therapy with currently available topical antifungals. However, advanced and nonresponding cases require surgical intervention for resolution of the infection.