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Early diagnosis, treatment of fungal keratitis key to preserving vision
Early identification and treatment are key to preserving vision in patients with fungal keratitis resulting from Exserohilum infection, according to a study.
In the retrospective, noncomparative observational study, records of 1,542 cases with keratomycosis were culled from the cornea service at the Aravind Eye Hospital in Tamil Nadu, India. Of these cases, 47 were caused by Exserohilum.
All patients underwent corneal scraping, were evaluated for significant culture growth and then received natamycin 5% topical treatment. Average time of first hospital visit after onset of symptoms was 6.2 days, and trauma was present in 38 cases. Results showed that 89.4% of cases responded well to topical treatment, therapeutic penetrating keratoplasty was necessary in 8.5% of cases, and 2.1% of cases progressed to endophthalmitis and required evisceration.
“Owing to rarity of the infection, there is no clinical study regarding the treatment protocol. However, case reports had shown that the infiltrate responds well to topical antifungals such as natamycin and itraconazole,” the study authors wrote.
Mean best corrected visual acuity improved from preoperative 0.89 logMAR to postoperative 0.77 logMAR.
“The patient will usually maintain good vision if the infection is diagnosed and treated early. The need for therapeutic PK in these patients seems to be less than that reported in other common fungal infections,” the authors wrote. – by Kate Sherrer
Disclosure: The authors report no relevant financial disclosures.
Perspective
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In this study, the authors identified from a retrospective review of culture-positive fungal corneal ulcers that the percent of Exserohilum cases was 3% of 1,542 cases. The majority were men who had suffered trauma with organic matter. The delay in presentation to a health care facility was approximately 6 days. Medical treatment with a combination of two topical antifungals proved to cure a majority, with approximately 8.5% requiring a corneal transplant in addition to the medical treatment.
A longer delay in presentation from the time of the onset of symptoms was associated with a greater failure rate of medical treatment. Early diagnosis and treatment are the most effective way to cure fungal keratitis. Delay in diagnosis will likely require surgical intervention in addition to medical treatment. It is important to have access to microbiologic studies to be able to identify the infecting organisms and best determine the appropriate treatment.
In summary, this study points to the importance of using the microbiology laboratory to identify unusual organisms, the importance of improved outcomes with early presentation and diagnosis, and that a significant number of fungal keratitis cases still require surgical treatment to eradicate infection. In the future, molecular diagnostics will provide better ways to make a precise diagnosis and more accurate information on treatment.
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Rathi H, et al. Cornea. 2016;doi:10.1097/ICO.0000000000000774.