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3/4/2017 FungalKeratitisClinicalPresentation:History,Physical,Causes

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FungalKeratitisClinicalPresentation
Updated:May20,2015
Author:DaljitSingh,MBBS,MS,DScChiefEditor:HamptonRoy,Sr,MDmore...

PRESENTATION

History
Ahistoryofoutdooreyetraumaoftenisreported.

Inpatientspresentingwithpossiblefungalkeratitis,inquireaboutpossibleriskfactors(seeCauses).

Symptomsincludethefollowing:

Foreignbodysensation
Increasingeyepainordiscomfort
Suddenblurryvision
Unusualrednessoftheeye
Excessivetearinganddischargefromtheeye
Increasedlightsensitivity

Physical
Theclinicaldiagnosisoffungalkeratitisisbasedonriskfactoranalysisandcharacteristiccorneal
features.

Themostcommonsignsonslitlampexaminationarenonspecificandincludethefollowing:

Conjunctivalinjection(Seeimagesbelow.)

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3/4/2017 FungalKeratitisClinicalPresentation:History,Physical,Causes

Fungalcornealulcer,withexcessivevascularization.
ViewMediaGallery

Marginalulcer,funguspositive.
ViewMediaGallery
Epithelialdefect
Suppuration(Seeimagesbelow.)

Fungalabscess.
ViewMediaGallery

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3/4/2017 FungalKeratitisClinicalPresentation:History,Physical,Causes

Fungalcornealabscess/ulcer.Aprovencaseoffungalinfection,5days'duration.Intenseinfiltrationaround
theabscess.
ViewMediaGallery
Stromalinfiltration
Anteriorchamberreaction
Hypopyon

Presentingclinicalfeaturesthatarespecifictofungalkeratitisincludeaninfiltratewithfeathery
margins,elevatededges,roughtexture,graybrownpigmentation,satellitelesions,hypopyon,and
endothelialplaque.Thespreadofinfectionoccursthroughthechannelnetworkofthecornea.This
modeofspreadfullyexplainsthesatellitelesions.

Fineorcoarsegranularinfiltratewithintheepitheliumandanteriorstroma
Graywhitecolor,dry,androughcornealsurfacethatmayappearelevated
Typicalirregularfeatheryedgedinfiltrate
Whiteringinthecorneaandsatellitelesionsneartheedgeoftheprimaryfocusoftheinfection
Inadvancedcases,suppurativestromalkeratitisassociatedwithconjunctivalhyperemia,
anteriorchamberinflammation,hypopyon,iritis,endothelialplaque,orpossiblecorneal
perforation

Althoughthesehighlycharacteristicsignsmaybepresent,obtainingasampleofthelesionby
scrapingorcornealbiopsyisimportantbeforeinitiatingtreatmentwithantifungaltherapy(see
Procedures).Severalunfortunatecaseshavebeenreportedinwhichantifungaltherapyhadbeen
initiatedbeforefungiwereseenorisolated,withresultantmisdiagnosisandprogressionofthe
process.Inwarmdevelopingcountries,itiswisetostartantifungalagentsonmeresuspicionsince
hotweatherpromotesrapidfungalgrowth.

Mixedbacterialandfungalinfectionsarecommoninthedevelopingcountries.Thepatientsmay
presentaftermanydaysorweeks.Whileantibacterialtherapyisstartedinmostclinicsinthe
periphery,fungalinfectionmaynotbeconsidered.Themostpracticalapproachingoodclinicsin
developingcountriesistoexamineascrapingfromtheulcer,bothforbacteriaandfungi.Ifhyphae
and/orsporesarefound,thetreatmenteffortsaremainlydirectedtowardthefungus,butbroad
spectrumantibioticsarealsousedtocoverforbacteria.

Onceafewfungalulcersorfungalkeratitiscaseshavebeencarefullyexamined,itbecomeseasyto
makeapresumptivediagnosisoffungusinfection.Inthedevelopingcountriesandtropics,fungal
casesareverycommoninthehotsummermonths.

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3/4/2017 FungalKeratitisClinicalPresentation:History,Physical,Causes

Advancedseverefilamentousfungalandyeastkeratitisareindistinguishableandresemblekeratitis
causedbyvirulentbacteria,suchasStaphylococcusaureusandPseudomonasaeruginosa.

Causes
Aspergillusisthemostcommoncauseoffungalkeratitisworldwide.However,theepidemiologyof
fungalkeratitisisclimatespecific.InthesouthernUnitedStates,Fusariumspeciesarethemost
commoncauseoffungalkeratitis,withanespeciallyhighincidenceinFlorida.Incontrast,Candida
andAspergillusspeciesarethemostcommonpathogensinthenorthernUnitedStates.

Commonriskfactorsforthedevelopmentoffungalkeratitisincludethefollowing:

Trauma(eg,contactlenses,foreignbody)inastudyoffungalkeratitisfromsouthFlorida,
traumawithvegetablematterwasthemajorriskfactorin44%ofpatients
Topicalcorticosteroiduse
Cornealsurgerysuchaspenetratingkeratoplasty,clearcornea(sutureless)cataractsurgery,
photorefractivekeratectomy,orlaserinsitukeratomileusis(LASIK)
Chronickeratitisduetoherpessimplex,herpeszoster,orvernalkeratoconjunctivitis
Youngmales
Healthy
Nosignificantoculardisease
Previoushistoryoftrauma(vegetablematter)
Agriculturaloccupations

RiskfactorsforCandidakeratitisareasfollows:

Olderpatients
Preexistingoculardisease
Exposurekeratopathy
Chronickeratitis
Longtermsteroiduse
Immunosuppressivedisease

DifferentialDiagnoses

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MediaGallery

Fungalcornealulcer.
Perforatedfungalulcer.
Fungalinfectionundertreatment.
Perforatedfungalcornealulcer.
Fungalulcerinanelderlywoman.
Fungalulcer.
Fungalcornealulcer,withexcessivevascularization.
Marginalulcer,funguspositive.
Healedfungalulcer.
Fungalkeratitis.
Cornealperforation,blockedbyacrystallinelensandbeingcoveredbyepithelium.
Fungalkeratitis,beingcontrolled.
Fungalinfection.
Fungalinfection.
Fungalabscess.
Fungalcornealabscess/ulcer.Aprovencaseoffungalinfection,5days'duration.Intense
infiltrationaroundtheabscess.
Surgicaltraumaproducingedemaandstriatekeratitis.Thecornealchannelsstandoutin
semiopaquecornealtissue,sincetheythemselvesarenotissuespaces.
Surgicaltraumaproducingedemaandstriatekeratitis.Thecornealchannelsstandoutin
semiopaquecornealtissue,sincetheythemselvesarenotissuespaces.
Anetworkofchannelsisvisibleinacaseofmegalocorneawithfaintopacificationofstroma.The
channelsstandoutasnonstructures.
Thiskindofopacificationistermedkeratitis.Anatomically,itappearstobeamicrochannel
structure.
Anetworkofcornealchannelsstandsoutinsidethearcussenilisofanoldpatient.Whatever
causestheopacificationinthecornealtissueisnotabletoopacifytheemptinessofcorneal
channels.
Networkofcornealchannelsina92yearoldpatient.
ThecornealchannelsopeninthelucidintervalchannelofSingh.
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PeripheralcornealchannelnetworkandcanalofSinghin3dimensions.
Opticalsectionofcornealchannelsinacaseofarcussenilis.
Thelucidintervalinopticalsectionclearlyshowsitstriangularconfigurationandananteriorand
posteriorwall.Theapexcontinuestowardscornealchannelsinthestroma.Thelucidinterval
channelisconnectedtolimballymphatics.
Thelucidintervalchannelisconnectedtothelymphaticsatthelimbusandthecornealchannels
centrally.
Abluntwireof100micrometersdiameterhasbeenpushedintothecanalofSingh.
A230micrometerbluntcannulainthecanalofSingh.
Thisnetworklikepatternoffungalcornealinfectionisexplainedonlybythepreferentialpathof
spreadthroughthecornealchannelnetwork.
Thefungalinfectiontravelsinvariousdirections.Alsoseenaresatellitelesions.Satellitelesions
andotherappearancesareexplainedbythepresenceofchannelsinthecornea.
Noticecentrifugal,linear,circular,andsatellitelikespreadoffungalinfectionthroughthecorneal
channels.
ThispatientpresentedwithinfectionofthelucidintervalofSinghwithoutanyevidenceof
cornealulcerationasastartingpoint,suggestingsystemicspread.Asatelliteofinfectionisseen
nearthe6o'clockposition.
SamepatientwithinfectionofthelucidintervalofSinghwithoutanyevidenceofcorneal
ulcerationasastartingpoint,suggestingsystemicspread.Abigandasmallsatelliteatthe6
o'clockposition.
ThesameeyeshowingthespreadoffungalinfectiononthenasalsideoftheSinghcanal.This
patientshowednoevidenceofcornealinjury,thusasystemicoriginofinfectionisadistinct
possibility.
ThewholeoftheinfectedlucidintervalcanalofSinghwasopened.Thescrapingshowedthe
presenceofhyphae.Thepatientwastreatedbyoralmedication,localdrops,andintracorneal
antifungalvoriconazoleinjections.Finalvisionwas6/6uncorrected.Therewasnorecurrence.
OpticalcoherencetomographyscansclearlyshowingthecanalofSinghconnectedtothe
Schlemmcanal.
OpticalcoherencetomographyscansclearlyshowingthecanalofSinghconnectedtothe
Schlemmcanal.
Fungalkeratitisundertreatment.Theinfectionhasspreadintothenearbylucidintervalcanalof
Singh.
Thesamecaseasinthepreviousphoto.Opticalcoherencetomographyscansshowsthe
presenceofexudatesinthelucidintervalcanalofSinghandtheadjoiningtrabecularmeshwork.

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ContributorInformationandDisclosures

Author

DaljitSingh,MBBS,MS,DScProfessorEmeritus,DepartmentofOphthalmology,GuruNanakDev
UniversityDirector,DaljitSinghEyeHospital,India

DaljitSingh,MBBS,MS,DScisamemberofthefollowingmedicalsocieties:AmericanSocietyof
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3/4/2017 FungalKeratitisClinicalPresentation:History,Physical,Causes

CataractandRefractiveSurgery,IndianMedicalAssociation,AllIndiaOphthalmologicalSociety,
IntraocularImplantandRefractiveSociety,India,InternationalIntraOcularImplantClub

Disclosure:Nothingtodisclose.

Coauthor(s)

ArunVerma,MDSeniorConsultant,DepartmentofOphthalmology,DrDaljitSinghEyeHospital,
India

Disclosure:Nothingtodisclose.

SpecialtyEditorBoard

FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedical
CenterCollegeofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.

ChristopherJRapuano,MDProfessor,DepartmentofOphthalmology,JeffersonMedicalCollegeof
ThomasJeffersonUniversityDirectoroftheCorneaService,CoDirectorofRefractiveSurgery
Department,WillsEyeHospital

ChristopherJRapuano,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanOphthalmologicalSociety,AmericanSocietyofCataractandRefractive
Surgery,CorneaSociety,ContactLensAssociationofOphthalmologists,EyeBankAssociationof
America,InternationalSocietyofRefractiveSurgery

Disclosure:Serve(d)asadirector,officer,partner,employee,advisor,consultantortrusteefor:Cornea
Society,AAO,OMIC,Aerie,Bausch&Lomb,BioTissue,Shire,TearLab<br/>Serve(d)asaspeakeror
amemberofaspeakersbureaufor:Allergan,Bausch&Lomb,BioTissue.

ChiefEditor

HamptonRoy,Sr,MDAssociateClinicalProfessor,DepartmentofOphthalmology,Universityof
ArkansasforMedicalSciences

HamptonRoy,Sr,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanCollegeofSurgeons,PanAmericanAssociationofOphthalmology

Disclosure:Nothingtodisclose.

Acknowledgements

GeorgeAlexandrakis,MDConsultingStaffandSurgeon,DepartmentofOphthalmology,Southern
CaliforniaPermanenteMedicalGroup

GeorgeAlexandrakisisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology

Disclosure:Nothingtodisclose.

AnastasiosJKanellopoulos,MDAssistantProgramDirector,ClinicalAssociateProfessor,
DepartmentofOphthalmology,ManhattanEye,Ear,andThroatHospital,NewYorkUniversity

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3/4/2017 FungalKeratitisClinicalPresentation:History,Physical,Causes

AnastasiosJKanellopoulos,MDisamemberofthefollowingmedicalsocieties:AmericanAcademy
ofOphthalmology,AssociationforResearchinVisionandOphthalmology,EyeBankAssociationof
America,andInternationalSocietyofRefractiveSurgery

Disclosure:Nothingtodisclose.

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