FUNGAL KERATITIS

MICHAEL B. VALDERRAMA
FUNGAL KERATITIS

Rare in temperate countries

Major cause of visual loss in tropical and developing countries.
Cause by two main types of fungi:
Yeasts (e.g. genus Candida)
Ovoid, unicellular organisms which reproduce by budding
Most common in temperate countires

Filamentous Fungi (e.g Fusarium and Aspegillus)

Multicellular organisms which reproduce by hyphae
Most common in tropical countries
PREDISPOSING FACTORS

Chronic ocular surface disease

Long-term use of topical steroids (often in conjunction with prior corneal
transplantation)
Contact lens wear
Systemic immunosuppression and diabetes.

Filamentary keratitis
Trauma, involving plant matter or gardening/agricultural tools.
CANDIDA AND FILAMENTOUS
KERATITIS
CLINICAL FEATURES

Presentation:
Gradual onset of pain
Grittiness
Photophobia
Blurred vision
Watery or mucopurulent discharge
SIGNS

Candida keratitis
Yellow white densely suppurative infiltrate
Collar-stud morphology

Candida keratitis
SIGNS
Filamentous keratitis
Grey or Yellow-white stromal infiltrate with
indistinct fluffy margins
Progressive infiltration often with satellite
lesions
Feathery branch-like extensions or a ring
shaped infiltrate may develop
Rapid progression with necrosis and
thinning can occur
Penetration of an intact Descemet
membrane may occur leading to
endopthalmitis without evident perforation
Filamentous keratitis with satellite
lesions and a small hypopyon
SIGNS

An epithelial defect is not invariable and is sometimes small when present.

Other features:
Anterior uveitis
Hypopyon
Endothelial plaque
Raised IOP
Scleritis
Sterile or infective endophthalmitis.
DIFFERENTIAL DIAGNOSES

Bacterial keratitis
Herpetic keratitis
Acanthamoebal keratitis
INVESTIGATIONS

1. Staining
Gram and Giemsa stain 50% sensitive
Periodic acid-Schiff (PAS) and Grocott-
Gomori methenamine-silver stain (GMS)
INVESTIGATIONS

2. Culture
Corneal scrapes, contact lenses and cases
Sabouraud dextrose agar
Blood agar
Enrichment media
INVESTIGATIONS

3. Corneal Biopsy
Indicated if with no clinical improvement in
3-4 days and if with no growth on culture
2-3mm block taken similar to scleral lock
excision during trabelectomy
4. Confocal microscopy
Rarely available
May permit identification of organisms in
vivo
TREATMENT

1. General measures are as for bacterial

keratitis although hospital admission is
usually required.

2. Removal of the epithelium over the

lesion may enhance penetration of antifungal
agents. It may also be helpful to regularly
remove mucus and necrotic tissue with a
spatula.
TREATMENT

3. Topical treatment should initially be given hourly for 48 hours and then reduced
as signs permit.
Treatment should be continued for at least 12 weeks.
a. Candida: Amphotericin B 0.15% or econazole 1%; alternatives include
natamycin 5%, fluconazole 2%, and clotrimazole 1%.
b. Filamentous: Natamycin 5% or econazole 1%; alternatives are amphotericin
B 0.15% and miconazole 1%.
c. A broad-spectrum antibiotic: to address or prevent bacterial co-infection.
d. Cycloplegia as for bacterial keratitis to control inflammation, pain and
photophobia
TREATMENT

4. Subconjunctival fluconazole may be used in severe cases.

5. Systemic antifungals
Severe cases
Lesions are near the limbus
Suspected endophthalmitis
Options include:
Voriconazole 400 mg b.d. for one day then 200 mg b.d.
Itraconazole 200 mg daily, reduced to 100 mg daily
Fluconazole 200 mg b.d.
TREATMENT

6. Tetracycline (e.g. doxycycline 100 mg

b.d.) may be given for its anticollagenase
effect when there is significant thinning.
7. IOP should be monitored using a Tono-
Pen.
8. Superficial keratectomy: to de-bulk
the lesion.
9. Therapeutic keratoplasty
(penetrating or deep anterior lamellar) is
considered when medical therapy is
ineffective or following perforation.
THANK YOU!