Medical management of Beauveria bassiana keratitis

PURPOSE: To describe a case of Beauveria bassiana keratitis and to discuss the management of this rare condition. METHODS: An 82-year-old woman underwent surgical repair of a graft wound dehiscence. Seven months later, shortly after the removal of sutures, the patient developed a fungal keratitis. B. bassiana was identified as the infecting organism. The patient was treated with topical natamycin and oral fluconazole. RESULTS: Following antifungal therapy, the corneal ulcer was eradicated, but the patient underwent repeat penetrating keratoplasty for decreased vision due to corneal edema. The graft remains clear and visual acuity is substantially improved. CONCLUSION: The medical management of B. bassiana keratitis has previously been unsuccessful. The use of topical natamycin combined with oral fluconazole in the management of this case is discussed.     

In vivo confocal microscopy in the diagnosis of fungal keratitis: case report

The authors describe a case of fungal keratitis that the in vivo confocal microscopy helped in the diagnosis and follow-up. Confocal microscopy was done in a patient's ulcer that did not improve with several topical medicines. Corneal scrapings were obtained and culture results were without conclusion. We observed hyphae and infectious collections on confocal microscopy. New corneal culture showed Fusarium sp ten days after confocal diagnosis.     

Successful Treatment of Lasiodiplodia theobromae Keratitis – Assessing the Role of Voriconazole

PurposeThe aim of this paper is to report the successful management of the first case of Lasiodiplodia theobromae keratitis in Hong Kong.MethodsWe conducted a case report.ResultsA 43-year-old Chinese male with a history of diabetes developed left eye keratitis after a trauma during tree felling. Fungal keratitis was diagnosed using a confocal microscope on day 1, and L. theobromae was confirmed from the culture. He was given oral voriconazole, topical natamycin, and topical and intracameral amphotericin B. The patient''s condition improved after the initial treatment. However, there was a slow progression to descemetocele formation and impending perforation due to corneal melting. Penetrating keratoplasty was performed at 8 weeks after presentation. Final visual recovery was good with no recurrence of infection. The cornea remained clear.ConclusionsWe report the first case of L. theobromae keratitis in Hong Kong, and it is the only case so far that involved the use of oral voriconazole in the combination therapy. Early recognition with the aid of confocal microscopy allowed the early start of treatment. The use of newer antifungal voriconazole topically and orally combined with topical amphotericin B appeared to be useful in the eradication of the fungus and prevention of recurrence. Intracameral antifungals might have improved the clinical management.Key Words: Lasiodiplodia theobromae, Keratitis, Voriconazole, Fungus     

Microsporidium stromal keratitis: in vivo confocal findings

PURPOSE: To relate the clinical signs, histopathologic features, and in vivo confocal biomicroscopy findings of a case of stromal microsporidial keratitis and to describe the use of in vivo confocal microscopy to monitor treatment effect. METHODS: An immunocompetent male patient presented with unilateral indolent stromal keratitis. Stromal microsporidiosis was confirmed after corneal biopsy. He underwent examination that used in vivo confocal microscopy (Heidelberg Retina Tomograph II and Rostock Cornea Module) before and after treatment with topical fumagillin and oral albendazole. Clinicopathologic correlation of the confocal scan was performed. RESULTS: Corneal biopsy showed extracellular microsporidium spores aligned along keratocytes and corneal lamellae. In vivo confocal scans showed similar morphology, with bright dots aligned along keratocytes. Treatment with antimicrobials and topical steroid gave resolution of active keratitis, correlating with disappearance of the bright spores on repeat in vivo confocal scanning. CONCLUSIONS: The in vivo confocal microscopy appearance of microsporidial keratitis corresponds to the histologic features from biopsy material. Treatment response may be monitored by using this technique, although definitive diagnosis requires corneal biopsy.     

Antifungal chemotherapy for fungal keratitis guided by in vivo confocal microscopy

Background To evaluate antifungal chemotherapy in patients with fungal keratitis guided by in vivo confocal microscopy. Methods A total of 121 patients (121 eyes) with fungal keratitis were enrolled in this study. Confocal microscopy was performed in real time after topical and/or oral antifungal chemotherapy. Hyphal density and morphology, composition of inflammatory cells, and appearance of corneal stromal cells at the central and peripheral corneal lesions were recorded. Antifungal therapy discontinued at 1 week after hyphae and inflammatory cells could not be detected, and affected corneal stromal cells became visible. Results Successful outcomes were achieved in 110 patients (90.9%). By confocal microscopy, we observed the gradual decrease of hyphae-positive sites and hyphal density during the chemotherapy. The inflammatory cells reduced in number and heterogeneity, while corneal stromal cells recovered. The antifungal drugs were tapered according to the changes in hyphae, inflammatory cells, and corneal stromal cells. There was no fungal recurrence during the 2-month follow-up period. The other 11 patients (9.1%) had deteriorated infection within 1 week of antifungal therapy, and therefore were subjected to corneal transplantation. Conclusions In vivo confocal microscopy appears to be an effective approach to guide antifungal chemotherapy. It allows comprehensive evaluation of hyphae, inflammatory cells, and corneal stromal cells in real time, and provides valuable and objective information required in selecting and adjusting therapeutic regimens for the treatment of fungal keratitis.     

Acinetobacter and Staphylococcus aureus ulcerative keratitis after laser in situ keratomileusis treated with antibiotics and phototherapeutic keratectomy

PURPOSE: To report a method of treatment for through-the-flap multibacterial ulcerative keratitis after laser in situ keratomileusis (LASIK). METHODS: Bacterial ulcerative keratitis after LASIK was treated with topical and systemic antibiotics followed by flap lifting, cleaning, and phototherapeutic keratectomy (PTK). Follow-up examinations included in vivo confocal microscopy, corneal topography, and wavefront analysis. RESULTS: Rapid recovery of the ulcerative keratitis was observed after flap lifting and cleaning of the interface and PTK combined with topical and systemic antibiotics. Two years postoperatively, corneal topography showed a slight depression of the ulcer area and decentration of the photoablation. Wavefront analysis revealed an irregular scan with a pronounced coma-like aberration, which with a wavefront-guided custom test lens correction provided 20/16 visual acuity. CONCLUSIONS: Ulcerative bacterial keratitis is a possible sight-threatening complication of LASIK refractive surgery. Lifting and rinsing the flap combined with cleaning of the flap interface with PTK may be helpful in these conditions when regression of the ulcer does not occur with topical and oral antibiotic treatment.     

共聚焦显微镜在真菌性角膜炎诊治中的临床应用

目的：评价共聚焦显微镜联合角膜刮片在真菌性角膜炎中的临床应用。

方法：对我院临床诊断为真菌性角膜炎的患者56例56眼行共聚焦显微镜检查和角膜刮片检查,包括涂片后显微镜下检查和真菌培养,并进行药物或联合手术治疗,统计诊断的阳性率和治疗预后。

结果：入院时共聚焦显微镜诊断阳性率为91%,角膜刮片病原学检测诊断阳性率为54%,共聚焦显微镜和角膜刮片联合诊断阳性率为95%。治疗后,单纯药物治疗达到临床治愈者44眼(79%),单纯药物治疗无法控制感染需要进行手术治疗者12眼(21%)。

结论：共聚焦显微镜具有非侵入性、快速、重复性好等特点,联合角膜刮片实验室检查可以提高真菌性角膜炎的诊断阳性率,更好地指导治疗。     

真菌性角膜炎70例早期临床诊断分析

目的:分析70例真菌性角膜炎早期临床诊断结果,评价共焦激光显微镜在真菌性角膜炎早期临床诊断中的应用价值。方法:用共焦激光角膜显微镜对临床拟诊为真菌性角膜炎的70例患者进行检查,同时行涂片检查真菌菌丝及培养查真菌菌落,对三组结果进行比较。结果:在70例患者中,根据病史、临床表现确诊为真菌性角膜炎,其中共焦激光角膜显微镜的确诊率为94%(66/70),角膜刮片的确诊率为31%(22/70),培养查真菌菌落确诊率为20%(14/70)。激光共焦角膜显微镜检查检出率高于角膜组织刮片(χ2=29.615,P<0.01)及真菌培养(χ2=39.433,P<0.01)检查。结论:共焦激光角膜显微镜是一种无创、快速、有效的活体检查方法,在真菌性角膜炎的早期诊断、治疗和研究中将起重要作用。     

Beauveria bassiana keratitis in bullous keratopathy: antifungal sensitivity testing and management

Purpose. Beauveria bassiana is a ubiquitous fungus available as an insecticide. In humans, it has limited virulence; to our knowledge, only 3 cases of invasive disease and 10 cases of keratitis have been documented. Methods and Results. We report the first case of B bassiana keratitis in a patient with aphakic bullous keratopathy. The fungal keratitis proved to be highly resistant to topical clotrimazole. Molecular identification was based on DNA sequence analysis. The minimal inhibitory concentrations (MIC) obtained were 2 μg/mL for voriconazole, 0.250 μg/mL for posaconazole, and >128 μg/mL for fluconazole; amphotericin B MIC was >16 μg/mL. In the absence of clinical improvement, a penetrating keratoplasty (PK) was performed. The patient was discharged on topical and systemic voriconazole and prednisolone 40 mg PO/day. The eye remained calm with a transparent cornea and clear anterior chamber. Conclusions. B bassiana keratitis is extremely rare, with only a few cases reported. Its risk factors are unknown. We report the first case in a patient with aphakic bullous keratopathy, which proved highly resistant to antifungal therapy (antifungal susceptibility results are presented). A PK was necessary for clinical improvement. A review of the literature is performed in an effort to define therapeutic strategies.     

Fungal keratitis caused by Cylindrocarpon lichenicola

We report a case of a 67-year-old woman with no significant past ocular history, who was referred for management of an unresponsive microbial keratitis resulting from trauma with a piece of clothing fabric 1 month previously in Portugal and worsening despite topical fortified antibiotics. On examination, visual acuity was limited to "light perception". Slit lamp examination revealed an 11×11mm full-thickness corneal infiltrate. Confocal images showed branching hyphae suggestive of a fungal infection. Fungal cultures of corneal scrapings revealed growth of Cylindrocarpon lichenicola, a saprophytic, filamentous fungus, which is an unusual cause of keratitis. Despite aggressive antifungal therapy with voriconazole and amphotericin B, she required penetrating keratoplasty for impending corneal perforation. Follow-up was uneventful, with no recurrence at 1 year. Fungal infections must be suspected in all corneal ulcers of traumatic etiology. Specific cultures and confocal microscopy must be performed early, so as to enable early treatment modification.     

真菌性角膜炎药物治疗后转归的共焦显微镜观察

目的探讨共焦显微镜对判断真菌性角膜炎经抗真菌药物治疗后转归的作用,为调整临床用药和选择治疗方案提供客观依据。方法2001年1月至2003年5月我院诊治的328例真菌性角膜炎患者中,选择共焦显微镜检查发现菌丝,溃疡直径≤5mm患者58例(58只眼),常规给予抗真菌药物治疗。分别在治疗前及治疗后7、14、28d和停药后7d对病灶的特定位点进行共焦显微镜检查,观察局部菌丝密度、炎性细胞密度和形态以及角膜基质细胞的变化,以此判断治疗效果,并根据情况调整用药;对共焦显微镜未查见真菌菌丝及炎性细胞的患者,巩固治疗1周后完全停药,并继续随访2个月,以观察有无真菌复发。结果53例患者在药物治疗7d时有明显好转,病灶缩小,共焦显微镜表现为查到菌丝的位点减少,菌丝密度降低,炎性细胞明显减少,形态趋于均匀,同时可见正常形态的角膜基质细胞出现;14d时,37例溃疡愈合,23例共焦显微镜未查见菌丝和炎性细胞;28d时,所有患者的角膜上皮已完全愈合,其中22例共焦显微镜检查仍可见浅基质中存在少量菌丝或未消退的炎性细胞,其余31例患者均未见菌丝和炎性细胞。以上53例位患者在随访期间均未见复发。另5例在用药7d内病情加重,共焦显微镜下见菌丝密度明显增加,炎性细胞增多,角膜基质破坏范围扩大,提示药物治疗效果不佳,故入院行角膜移植术。结论共焦显微镜检查是目前判断真菌性角膜炎药物治疗后病情转归的理想手段,能够为临床调整用药提供客观依据。(中华眼科杂志,2005,41：614-619)     

Scytalidium keratitis: case report in a human eye

PURPOSE: To describe the presentation and treatment of a case of an atypical reticular corneal infiltrate with surrounding immune-like ring in a young woman caused by Scytalidium fungal species. METHODS: Interventional case report describing the clinical appearance, course, and treatment of Scytalidium keratitis. RESULTS: A 21-year-old female equestrian with a history of soft contact lens wear was noted to have persistent keratitis and photophobia of the right eye after an injury with a volleyball. Although initially culture negative and responsive to topical steroids, the keratitis persisted, and repeat corneal scrapings and cultures revealed Scytalidium species. Treatment with topical amphotericin B 0.15% and oral fluconazole 200 mg twice daily eradicated the infection, and the patient had a final best-corrected visual acuity of 20/20. CONCLUSION: Scytalidium species fungal organisms can cause an indolent keratitis. Intensive oral and topical antifungal therapy was successful in eradicating the infection.     

Polymicrobial keratitis secondary to Burkholderia ambifaria, enterococcus, and staphylococcus aureus in a patient with herpetic stromal keratitis

PURPOSE: To report polymicrobial keratitis in a patient with herpetic stromal keratitis. The initial infecting organism, Burkholderia ambifaria, has not previously been reported to cause microbial keratitis. METHODS: Clinical evaluation and corneal culture were performed. RESULTS: A 59-year-old-man undergoing topical corticosteroid therapy for herpes simplex stromal keratitis developed corneal infection with B. ambifaria. The organism was reisolated 12 days after initiation of hourly therapy with topical levofloxacin 0.5%. At reculture Staphylococcus aureus and Enterococcus spp. were also isolated. The addition of topical amikacin and vancomycin led to resolution of the microbial keratitis. CONCLUSIONS: Burkholderia ambifaria infected a compromised cornea, exhibited an unusual sensitivity profile, and remained viable after 12 days of therapy with an antibiotic to which it was sensitive by in vitro tests.     

共焦显微镜在棘阿米巴性角膜炎临床诊断中的应用

目的 :评价共焦显微镜 (confocalmicroscopy)在棘阿米巴性角膜炎 (acanthamoebakeratitis)临床诊断 ,尤其是早期诊断中的应用价值。方法 :对临床拟诊为棘阿米巴性角膜炎患者 2 3例进行共焦显微镜检查 ,并同时行角膜涂片及棘阿米巴原虫培养检查 ,对两种检查方法的结果进行比较。结果 :2 3例患者中 ,13例共焦显微镜检查可见棘阿米巴包囊和 /或神经炎表现 ,综合各项检查结果及临床表现 ,18例确诊为棘阿米巴性角膜炎 ,共焦显微镜的阳性率为 5 6 5 %。在 5例表现为上皮性及浅基质病变的早期角膜炎患者 ,共焦显微镜检查 3例 (6 0 % )为阳性 ,刮片、培养各 1例 (2 0 % )为阳性。结论 :共焦显微镜检查是一种无创、快速和有效的活体检查手段 ,在棘阿米巴性角膜炎的诊断中 ,如同时结合实验室刮片及培养和患者临床情况可起到重要的辅助诊断作用 ,尤其是在棘阿米巴角膜炎的早期诊断中 ,可以起到更重要的作用     

Confocal microscopy of Aspergillus fumigatus keratitis

AIM: To use a confocal microscope to characterise the treated and untreated courses of fungal keratitis. METHODS: In the first experiment, Aspergillus fumigatus stromal keratitis was produced in both eyes of seven New Zealand white rabbits. In the second experiment, keratitis was induced in right eyes of 20 rabbits. Group 1 rabbits were treated with topical fluconazole, group 2 rabbits received oral fluconazole, and group 3 rabbits were used as controls. The rabbits were examined with a slit lamp and confocal microscope 2, 6, 10, 14, and 20 days after inoculation. The corneal cultures were taken on days 2, 14, and 20 and biopsies were taken on days 2 and 22. RESULTS: On days 14 and 22 confocal microscopy was more sensitive than culture technique in both treated and untreated animals, since not all cases of fungal keratitis can be cultured. CONCLUSION: This study indicates that confocal microscopy is a rapid and sensitive diagnostic tool for both the early diagnosis and non-invasive follow up of fungal keratitis     

共聚焦显微镜在真菌性角膜炎中的应用

目的:探讨共聚焦显微镜在真菌性角膜炎中的应用价值。方法:回顾性分析在我院就诊的拟诊为真菌性角膜炎患者42例42眼,行共聚焦显微镜检查,同时行角膜病灶组织刮片染色检查。结果:真菌性角膜炎患者42例42眼,行共聚焦显微镜检查,观察到真菌菌丝为39例39眼,检出阳性率93%(39/42),行角膜病灶组织刮片染色镜检,观察到真菌菌丝为30例30眼,检出阳性率71%(30/42)。统计学分析表明两者差异有统计学意义(χ2=6.574,P<0.05)。结论:共聚焦显微镜是一种无创、高效、直观的检查设备,对真菌性角膜炎的初步诊断有着重要的临床价值。     

Voriconazole in the management of Alternaria keratitis

PURPOSE: To discuss the role of voriconazole in the management of Alternaria keratitis. METHODS: Case report and literature review. RESULTS: A 69-year-old man with a history of corneal foreign body removal developed a stromal infiltrate 2 months later that did not improve despite topical antibiotics and natamycin. On our initial examination, visual acuity (VA) was 20/40, and he had a central, full-thickness, reticular appearing infiltrate. Oral clarithromycin was added because of the atypical pattern of the infiltrate. However, no improvement was noted. A repeat culture revealed coagulase-negative Staphylococcus. VA decreased to 20/200, and increased inflammation was noted a month later; a trial of topical steroids was added. After an initial improvement, he returned with progression. Repeat culture revealed Alternaria species, and topical amphotericin was started. When there was no response, he was admitted and switched to oral and topical voriconazole. Steady resolution was noted within 10 days of therapy. CONCLUSION: Suspicion must be maintained for unusual causes of infectious keratitis. Fungal infection can be difficult to eradicate even with traditional antifungals. Although not approved for ophthalmic use yet, voriconazole provided improvement with Alternaria keratitis unresponsive to amphotericin.     

Clinical response of contact lens-associated fungal keratitis to topical fluoroquinolone therapy

PURPOSE: To report 5 cases of fungal keratitis associated with contact lens wear that resolved or significantly improved without antifungal therapy. METHODS: Observational case report of 5 patients with a history of contact lens wear who presented with infectious keratitis. Two patients had growth of fungal species on corneal microbiologic cultures, and of the remaining 3 patients, 2 showed fungal elements on confocal microscopy. All 5 patients exhibited growth of fungal species on contact lens microbiologic cultures. All patients received topical fluoroquinolone therapy as initial treatment. RESULTS: In 3 cases, of whom 2 were treated with moxifloxacin 0.5%, the keratomycosis resolved completely on topical fluoroquinolone therapy. One case was switched to topical tobramycin 14 mg/mL and cefazolin 50 mg/mL with complete resolution of the infection. The final case showed marked initial improvement on fluoroquinolone therapy but was subsequently treated with natamycin 5%. CONCLUSIONS: Fungal keratitis associated with soft contact lens wear may occasionally present in a less aggressive form. Topical fluoroquinolone therapy may be an adjunct to the innate immune response in eradicating less fulminant keratomycosis.     

Successful treatment of resistant ocular fusariosis with posaconazole (SCH-56592)

PURPOSE: To describe the successful treatment with systemic posaconazole of a series of Fusarium ocular infections refractory to other antifungal agents. DESIGN: Retrospective, interventional case series. METHODS: We identified three patients from three different centers who received diagnoses of Fusarium keratitis and who received systemic posaconazole after their infections failed to respond to maximal tolerated medical and surgical therapy. All patients received multiple systemic, intracameral, and topical antifungal agents, which were ineffective in controlling their infection. RESULTS: Two patients were contact lens wearers. Two patients developed endophthalmitis. The infections of all three patients failed to respond to systemic and/or topical voriconazole treatment. One patient could not tolerate systemic voriconazole, and another experienced no marked improvement. The third discontinued treatment for both reasons. All patients were treated with oral posaconazole and experienced rapid reduction of intraocular inflammation and pain, as well as resolution of the infection without additional intervention. CONCLUSIONS: Deep Fusarium keratitis is difficult to treat and carries a high risk of progression to endophthalmitis. Posaconazole, which exhibits excellent tissue penetration and demonstrates efficacy in the treatment of systemic Fusarium infection, was successful in treating three cases of pan-resistant keratitis and/or endophthalmitis.     

Aureobasidium pullulans fungal keratitis following LASEK

PURPOSE: To describe a patient who developed Aureobasidium pullulans keratitis following refractive laser epithelial keratomileusis (LASEK). METHODS: A 52-year-old woman was referred to a tertiary care center 1 month after LASEK for treatment of a corneal ulcer that was unresponsive to conventional therapy. Mycology culture and fungal stain identified Aureobasidium as the infectious organism. RESULTS: The infection responded well to treatment with topical natamycin and systemic itraconazole. CONCLUSIONS: Treatment with topical natamycin and systemic itraconazole is effective against Aureobasidium pullulans keratitis.