眼部机会感染的误诊分析

目的探讨眼部机会感染误诊的原因。方法对４例（６只眼）的眼部机会感染患者的误诊原因进行分析。结果棘阿米巴性用膜炎误诊为单疮病毒性角膜炎和真菌性角膜炎１例（１只眼）；痤疮丙酸杆菌性眼内炎误诊为外源性真菌性眼内炎１例（１只眼）；内源性真菌性眼内炎误诊为脉络膜转移性肺癌１例（２只眼）；巨细胞病毒性视网膜炎误诊为内源性真菌性眼内炎１例（２只眼），结论上述疾病按常规方法治疗无效和反复检查仍查不到致病菌时，应警惕少见的眼部机会感染的可能，必须做特殊检查（棘阿米巴、厌氧菌培养、真菌血液培养、巨细胞病毒血清学检测等），才能明确诊断。     

A retrospective analysis of infection after corneal transplantation

PURPOSE: We studied retrospectively the background of postoperative infection after corneal transplantation. METHODS: We reviewed the records of 753 eyes that had undergone corneal transplantation at Kyoto Prefectural University of Medicine or the Baptist Eye Clinic over a period of 6 years from April 1994 to March 2000. Patients who developed microbial keratitis after corneal transplantation were evaluated for the incidence of infection, age, the interval between transplantation and infection, microbiological etiology, the use of topical steroids, therapy, and complications. RESULTS: Follow-up after keratoplasty averaged 43.2+/-25.6 months (mean+/-standard deviation). Among 753 eyes examined, microbial keratitis developed in 27 eyes (3.6%), 14 eyes had bacterial, and 13 had fungal infections. The ages at presentation were 51.4+/-21.5 years for bacterial infections, and 66.5+/-11.1 for fungal infections. The time intervals between transplantation and the onset of infection averaged 7.8+/-7.9 months for bacterial infections, and 24.2+/-17.2 for fungal infections. Infections in 7 (50.0%) of the bacterial eyes were caused by methicillin-resistant Staphylococcus aureus (MRSA) or epidermidis (MRSE), and 9 (69.2%) of the fungal infections by yeast type fungus (8 were Candida species). At onset of keratitis, 3 (21.4%) of the bacterial eyes and 6 (46.2%) of the fungal eyes were treated with fluorometholone, and 11 (78.6%) of the bacterial eyes and 7 (53.8%) of the fungal eyes were treated with betamethazone or dexamethasone. The treatment duration until the focus of disappeared was 32.8+/-19.7 days for bacterial eyes, and 74.8+/-56.3 for fungal eyes. Major complications associated with infection included corneal perforation in 2 eyes of both the bacterial (14.3%) and fungal (15.4%) eyes, graft rejection in 4 (28.6%) bacterial eyes and 1 (7.7%) fungal eye, there was no recurrence of infection in the bacterial eyes but there were 3 (23.1%) cases of recurrence in the fungal eyes. CONCLUSIONS: Infection after corneal transplantation is opportunistic. Fungal infections occurred later than bacterial infections. Also in fungal infections, the mean age at presentation was higher and the recurrence of infection was more frequent.     

The etiology of infectious corneal ulceration in Sierra Leone

The microbial etiology of infectious corneal ulceration in Sierra Leone has been investigated. Patients either presenting to district health centers or encountered on rural surveillance expeditions with suspected infectious ulcerative keratitis were recruited into the study. Infectious corneal ulceration was defined as clinical evidence of corneal infection with epithelial defect with or without hypopyon. Cultures were obtained in a standard fashion and subsequent microbial analysis performed on all specimens. Seventy-three (73) cases of suspected infectious ulcerative keratitis were obtained between January 2005 and January 2006. The most commonly isolated organisms from microbial cultures of infected eyes were Gram-negative bacteria (45.2%), Gram-positive bacteria (37.0%), and fungal species (35.6%). Mixed bacterial and fungal organisms were isolated from ten eyes (13.7%) and no organisms were isolated from four eyes (5.5%). There is a high incidence of Gram-negative and fungal ulcerative keratitis in the population studied in Sierra Leone. Empirical therapy for corneal ulceration in this region should be aimed towards treatment of bacterial, fungal, and mixed infections.     

Spectrum of fungal keratitis at Wills Eye Hospital, Philadelphia, Pennsylvania

PURPOSE: To report the spectrum of fungal keratitis at Wills Eye Hospital, Philadelphia. METHODS: We reviewed the records of 24 cases of culture-positive fungal keratitis treated from January 1991 to March 1999 at Wills Eye Hospital. Risk factors, fungal identification, antifungal treatment, and outcomes were evaluated. RESULTS: The study included 24 eyes (24 patients). Fourteen patients (58.3%) were female. The mean age was 59 years (range, 19-86 years). Predisposing factors included chronic ocular surface disease (41.7%), contact lens wear (29.2%), atopic disease (16.7%), topical steroid use (16.7%), and ocular trauma (8.3%). Early identification of fungal elements was achieved by staining of corneal scrapings in 18 cases (75%). Half of the cases (12 eyes) had corneal infections caused by yeast, and the other half by filamentous fungi. Candida albicans was the most commonly isolated organism (45.8%), followed by Fusarium sp (25%). Natamycin and amphotericin B were the topical antifungals most frequently used, while systemic treatment commonly used included fluconazole, ketoconazole, or itraconazole. Six patients (25%) had penetrating keratoplasty during the acute stage of infection. After a mean follow-up of nine months, 13 eyes (54.1%) had the best corrected visual acuity 20/100 or better. CONCLUSIONS: In contrast to other studies from the northern United States, we found Fusarium sp the most commonly isolated filamentous fungus. In our series, C. albicans was the most frequent cause of fungal keratitis, and a past history of ocular trauma was uncommon.     

Microsphaeropsis olivacea keratitis and consecutive endophthalmitis

PURPOSE: To report a case of fungal keratitis with consecutive endophthalmitis caused by Microsphaeropsis olivacea. METHODS: Case report. RESULTS: A 51-year-old man developed fungal keratitis and consecutive endophthalmitis after sustaining a penetrating injury to the right eye. Cultures of the aqueous humor yielded M. olivacea. Infection resolved after intraocular fungal debridement, intravitreous amphotericin B, and aggressive topical natamycin and oral fluconazole. Persistent, low-grade smoldering corneal and intraocular inflammation required topical corticosteroid therapy. CONCLUSION: M. olivacea is an exceedingly rare ocular pathogen. The intraocular portion of the infection responded quickly to intravitreal antifungal treatment; however, the course was prolonged by smoldering corneal inflammation. Prompt recognition of intraocular spread and aggressive treatment may be beneficial in fungal infections caused by unusual organisms with uncertain virulence.     

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.     

Intracorneal injection of amphothericin B for recurrent fungal keratitis and endophthalmitis

Penetrating keratoplasty carries an infectious risk. Its requirement for topical corticosteroid therapy facilitates fungal growth with resulting keratitis. Although progression of fungal keratitis to intraocular infection is uncommon, endophthalmitis resulting from keratitis usually has a poor visual prognosis. Fungal infection under these circumstances remains a diagnostic and therapeutic challenge. We report a complicated case of recurrent fungal keratitis with endophthalmitis following a contaminated penetrating keratoplasty that ultimately was controlled with a new treatment modality. Intrastromal corneal injections combined with intravitreal injection of amphotericin B led to the eradication of the corneal fungal plaques and the intraocular infection. Intrastromal corneal injections of amphotericin B may offer a less invasive, in-office alternative to repeat penetrating keratoplasty.     

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.     

Comparison of outcomes in patients with and without soft contact lens wear following Boston keratoprosthesis type 1

ObjectiveTo compare the rate of long-term complications in Boston keratoprosthesis type 1 (KPro) patients with and without soft contact lens wear (SCL).MethodsA chart review was performed on patients who underwent KPro type 1 surgery from January 2008 to June 2018 performed by a single surgeon at the University of Montreal Hospital Centre. Ninety-nine KPro patients (114 eyes) were separated into group 1 (patients with SCL) and group 2 (patients without SCL) at 1 and 5 years. Survival at 1- and 5-year follow-ups is defined as the absence of complications: corneal melts, leaks, retroprosthetic membrane, infectious keratitis, sterile vitritis, endophthalmitis, and KPro extrusion.ResultsThe mean SCL retention duration was 3.17 years. Overall, the survival distribution of both groups was not significantly different. At 1 year, group 1 achieved a higher KPro survival rate (75.11%) than group 2 (61.39%; p = 0.248). At 5 years, group 1 had a lower survival rate (49.11%) than group 2 (65.22%; p = 0.127). Although not statistically significant, the percentage of individual complications was higher in group 2 at 1 year (p = 0.3040) and lower in group 2 at 5 years (p = 0.6089) compared with group 1.ConclusionThe mean SCL retention duration in our study was longer than previously reported. Long-term SCL does not significantly decrease the rate of complications. A prospective study is warranted to further examine the outcomes of long-term SCL wear.     

Review of endophthalmitis following Boston keratoprosthesis type 1

Endophthalmitis remains one of the most damaging and challenging complications following Boston keratoprosthesis type 1 (KPro) surgery. The authors reviewed the literature from 2001 onward to identify cases of endophthalmitis following KPro surgery and present an additional case of endophthalmitis in a patient with Stevens Johnson syndrome. The prevalence of endophthalmitis between 2001 and 2011 was 5.4%. Gram-positive bacteria are the most common agents responsible for endophthalmitis in this patient population while gram-negative bacteria and fungi are emerging pathogens. Risk factors for endophthalmitis include preoperative diagnosis of cicatricial disease and postoperative infectious keratitis, glaucoma drainage device erosion and non-compliance with antibiotic prophylaxis. Additional studies on the prevention and treatment of endophthalmitis are required to improve the overall prognosis of these patients.     

Late Bacterial and Fungal Keratitis after Corneal Transplantation: Spectrum of Pathogens,Graft Survival,and Visual Prognosis

The authors reviewed 108 bacterial and fungal corneal ulcers that developed 1 to 72 months after penetrating keratoplasty in 79 eyes of 78 patients. Graft hypesthesia, topical corticosteroid and antibiotic treatment, exposed sutures, epithelial defects, and poor visual acuity commonly predated infectious keratitis. There were 69 bacterial, 34 fungal, and 5 combined infections. Candida albicans and Staphylococcus epidermidis were the most common pathogens. Follow-up after infection averaged 23 months (range, 1–80 months). Despite hospitalization and fortified topical antibiotic treatment, complications such as wound dehiscence and corneal perforation necessitated emergency regraft in 38 (35%) cases. Of 73 previously clear grafts, only 29 (40%) retained clarity. Median visual acuity, 20/200 before infection, fell to counting fingers at last follow-up; 12 eyes lost light perception.     

Fusarium-Keratitis

The case of a previously healthy 48-year-old patient (not a contact lens wearer) with a Fusarium keratitis is reported. He had developed a deep corneal ulcer with total stromal infiltration (Fusarium ssp.). An intensive topical and systemic antiinfectious medication was initiated, along with some procedures (keratoplasty, rinsing of the anterior chamber). However, the infection progressed (endophthalmitis), and an enucleation was necessary. Despite modern drug therapy and surgical intervention, fungal keratitis can cause an enucleation.     

Fungal keratitis at the new york eye and ear infirmary

INTRODUCTION: This study was designed to review the clinical experience at our institution with fungal keratitis during a 16-year period. MATERIALS AND METHODS: A review of the clinical and microbiology records of the New York Eye and Infirmary identified 61cases of fungal keratitis in 57 patients between January 1, 1987 and June 1, 2003. The medical records of all patients were retrospectively reviewed to better delineate patient demographics, risk factors, etiologic organisms, treatment, and outcomes. RESULTS: A total of 5083 positive corneal cultures were recorded'from January 1, 1987 to June 1, 2003. Sixty-one eyes in 57 patients (37 women) were positive for fungus (1.2%). Three'patients had bilateral simultaneous infections. Candida albicans accounted for 29 of 61 cases (48%). Human immunodeficiency virus (HIV) seropositivity (15 eyes), chronic ocular surface disease (14 eyes), and trauma (7 eyes) were the most commonly associated risk factors. CONCLUSIONS: Our experience with fungal keratitis in the northeastern United States appears to be different than those reported from other areas of the United States. Serologic positivity for HIV and chronic ocular surface disease were the most common associated risk factors followed by trauma, herpes simplex keratitis, and contact lens use. Candida species predominated, whereas filamentous fungi were uncommon.     

Therapeutic contact lens-related bilateral fungal keratitis.

PURPOSE: To describe a rare case of bilateral Candida keratitis after contact lens use following bilateral penetrating keratoplasty (PK). METHODS: A 40-year-old female with a clinical diagnosis of Sj?gren's syndrome was being followed for corneal thinning in both eyes. She suffered a spontaneous bilateral perforation and underwent penetrating keratoplasty. Therapeutic contact lenses were prescribed for both eyes owing to persistent epithelial defects. Two months later, a biomicroscopic examination revealed corneal infiltrates. RESULTS: A corneal tissue sample, saline, and contact lens cultures were all positive for Candida albicans. Topical and systemic antifungal therapy successfully cleared the infection in the right eye; however, the left eye underwent another corneal graft surgery. CONCLUSIONS: Infectious fungal keratitis may be a complication of wearing therapeutic contact lenses after PK, in a patient with Sj?gren's syndrome. The pre-existing eye disease is an important associated factor in cases of yeast infection; therefore, adequate care of these patients and careful follow-up after PK are indicated as measures to prevent early infections.     

Fungal keratitis in London: microbiological and clinical evaluation

PURPOSE: To review cases of culture-positive fungal keratitis seen at Moorfields Eye Hospital over a 13-year period to January 2007. METHODS: Isolates were identified retrospectively from laboratory reports. The clinical records were reviewed. The fungal type, risk factors for infection, in vitro sensitivity, and clinical outcome were recorded. RESULTS: There were 66 isolates from 65 patients (men, 53.8%). Forty (60.6%) of the isolates were subspecies of Candida. The average interval from the onset of keratitis to confirmation of fungal infection was 3.4 weeks (median, 1.0 week; range, 0-16 weeks). Prior ocular surface disease (OSD) or a penetrating keratoplasty (PK) was present in 38 (97.4%) patients with Candida infection, and 29 (74.4%) patients with Candida infection were using topical steroid at the time of diagnosis. The principal risk factors for filamentary fungal infection were trauma (8 cases, 30.8%) or cosmetic contact lens wear (8 cases, 30.8%), with OSD or a prior PK each present in 5 (19.2%) cases. The difference in the proportions of risk factors between the 2 fungal groups was statistically significant (P < 0.000). The visual outcome was similar between groups, and at final review, 27 (41.5%) eyes had a visual acuity of < or = 1/60 and 3 (4.6%) eyes were eviscerated. In vitro sensitivity testing showed full or part sensitivity in 100% of 55 isolates tested against econazole, 87.9% of 58 isolates tested against amphotericin, 75% of 40 isolates tested against itraconazole, and 100% of 20 isolates tested against voriconazole. CONCLUSIONS: Candida was the principal isolate, usually from eyes with OSD or a prior PK treated with topical steroids.     

Advanced fusarium keratitis progressing to endophthalmitis

PURPOSE: To review the clinical course, treatment, and visual outcomes of keratitis with endophthalmitis caused by the filamentary fungus Fusarium. METHOD: One hundred fifty-nine cases of Fusarium keratitis at Bascom Palmer Eye Institute between January 1, 1987 and August 21, 2000 were reviewed. Ten patients with culture-proven Fusarium keratitis progressed to endophthalmitis. All 10 underwent standard diagnostic microbiologic evaluation, and topical and oral antifungal therapy was instituted. Surgical therapy was applied when necessary. Main outcome measures included the incidence of intraocular invasion of fungal keratitis and response to treatment. RESULTS: Ten cases of 159 Fusarium keratitis patients had intraocular involvement that was culture proven. The isolated species were Fusarium oxysporum in seven cases and Fusarium solani in two cases, and in one case, the species could not be identified. Cultures of aqueous and intraocular tissues grew Fusarium in eight cases, whereas vitreous cultures were positive in two. Nine cases had preexisting risk factors. All patients received oral ketoconazole or fluconazole and topical natamycin 5%. In two cases, intravitreal amphotericin B injections were also given. Four patients required a penetrating keratoplasty, enucleation was performed in two patients, two patients required a combination of a penetrating keratoplasty and pars plana vitrectomy, and one patient developed phthisis. CONCLUSION: The combination therapy with oral imidazoles (fluconazole or ketoconazole) and topical natamycin is inadequate in severe Fusarium keratitis with intraocular spread. Early diagnosis and suspicion of endophthalmitis in patients with keratomycosis not responding to aggressive topical antifungal are important.     

Fungal keratitis in a soft contact lens wearer.

PURPOSE: To describe a case of fungal keratitis in a soft contact lens wearer. METHODS AND RESULTS: A 57 year old female, compliant, frequent replacement soft contact lens wearer, with a possible prior history of herpes simplex keratitis, presented with pain and injection of her left eye of four weeks duration. Gram stain of a corneal ulcer of the left eye revealed fungal organisms and cultures grew Fusarium solani. The infiltrate responded to topical and systemic antifungal agents, but a corneal perforation developed which required a therapeutic penetrating keratoplasty. CONCLUSIONS: Fungal infections are a cause of corneal ulcers in contact lens wearers. Despite the use of topical and systemic antifungal agents, fungal ulcers frequently require surgical intervention.     

Corneal concentrations following systemic administration of amphotericin B and its lipid preparations in a rabbit model

BACKGROUND: Amphotericin B (AmB) and various lipid formulations of AmB are available for the treatment of fungal infections of the eye. Currently, the recommended route of administration for the treatment of fungal keratitis is by topical application. Nevertheless, because of the risk of a difficult to treat exogenous fungal endophthalmitis, a combined topical and systemic treatment is frequently given when treating deep fungal keratitis. To date, little is known about the pure corneal availability of these drugs following systemic treatment. In this study, the corneal concentration following 7 daily doses of parenteral AmB lipid complex (ABLC) or liposomal AmB (L-AmB) was compared to that of AmB deoxycholate (D-AmB) in a rabbit model. METHODS: Following induction of uveitis in one rabbit eye by intravitreal injection of endotoxin, daily doses of D-AmB (1 mg/kg), ABLC (5 mg/kg) or L-AmB (5 mg/kg) were given intravenously on 7 consecutive days. Five or more rabbits per treatment were used. AmB concentrations were determined by high-performance liquid chromatography (HPLC) in corneas collected at autopsy 24 h after the 7th and final dose. Data were analyzed using the Mann-Whitney U test. RESULTS: After 7 days of treatment, mean corneal concentrations of AmB in the inflamed eyes were significantly higher (2.38 +/- 1.47 microg/g; p < 0.01) following treatment with L-AmB compared with ABLC (<0.1 microg/g) and D-AmB (0.46 +/- 0.2 microg/g). No AmB could be detected in the corneas of the non-inflamed eyes. CONCLUSION: In our rabbit model, AmB penetration into the cornea was significantly higher after systemic administration of L-AmB compared with conventional D-AmB or ABLC.     

Exogenous fungal endophthalmitis

The authors report 19 cases of exogenous fungal endophthalmitis managed between 1969 and 1986. These developed after ocular surgery (5 cases), after trauma (6 cases), by intraocular spread from fungal keratitis (4 cases), after therapeutic keratoplasty for keratitis (3 cases), and by spontaneous infection of a filtration bleb (1 case). The diagnosis of endophthalmitis was made from 3 days to 4 months after surgery or trauma. In patients with preexisting keratitis, endophthalmitis was noted 2 weeks to 5 months after the onset of keratitis. Seventeen cases were caused by filamentous fungi; two were caused by yeast. Fusarium (6 cases) and Acremonium (3 cases) accounted for approximately one half of the isolates. Forty-two percent of the patients recovered 20/400 or better acuity (3 of 5 postoperative cases, 4 of 6 trauma cases, and 1 of 4 keratitis cases). The clinical and microbiologic features of these cases are presented, and recommendations for management are offered.