Fungal Keratitis Clinical Presentation

  • Author: Daljit Singh, MBBS, MS, DSc; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Oct 27, 2011
 

History

A history of outdoor eye trauma often is reported.

In patients presenting with possible fungal keratitis, inquire about possible risk factors (see Causes).

Symptoms include the following:

  • Foreign body sensation
  • Increasing eye pain or discomfort
  • Sudden blurry vision
  • Unusual redness of the eye
  • Excessive tearing and discharge from the eye
  • Increased light sensitivity
Next

Physical

The clinical diagnosis of fungal keratitis is based on risk factor analysis and characteristic corneal features.

The most common signs on slit lamp examination are nonspecific and include the following:

  • Conjunctival injection (See images below.)Fungal corneal ulcer, with excessive vascularizatiFungal corneal ulcer, with excessive vascularization. Marginal ulcer, fungus positive. Marginal ulcer, fungus positive.
  • Epithelial defect
  • Suppuration (See images below.)Fungal abscess. Fungal abscess. Fungal corneal abscess/ulcer. A proven case of funFungal corneal abscess/ulcer. A proven case of fungal infection, 5 days' duration. Intense infiltration around the abscess.
  • Stromal infiltration
  • Anterior chamber reaction
  • Hypopyon

Presenting clinical features that are specific to fungal keratitis include an infiltrate with feathery margins, elevated edges, rough texture, gray-brown pigmentation, satellite lesions, hypopyon, and endothelial plaque.

  • Fine or coarse granular infiltrate within the epithelium and anterior stroma
  • Gray-white color, dry, and rough corneal surface that may appear elevated
  • Typical irregular feathery-edged infiltrate
  • White ring in the cornea and satellite lesions near the edge of the primary focus of the infection

In advanced cases, suppurative stromal keratitis associated with conjunctival hyperemia, anterior chamber inflammation, hypopyon, iritis, endothelial plaque, or possible corneal perforation

Although these highly characteristic signs may be present, obtaining a sample of the lesion by scraping or corneal biopsy is important before initiating treatment with antifungal therapy (see Procedures). Several unfortunate cases have been reported in which antifungal therapy had been initiated before fungi were seen or isolated, with resultant misdiagnosis and progression of the process.

A deep stromal infiltrate with an intact epithelium also may be present. However, many fungal ulcers demonstrate no striking morphologic pattern, and it often is not possible to differentiate clinically between fungal keratitis and bacterial keratitis.

Advanced severe filamentous fungal and yeast keratitis are indistinguishable and resemble keratitis caused by virulent bacteria, such as Staphylococcus aureus and Pseudomonas aeruginosa.

Previous
Next

Causes

Aspergillus is the most common cause of fungal keratitis worldwide. However, the epidemiology of fungal keratitis is climate specific. In the southern United States, Fusarium species are the most common cause of fungal keratitis, with an especially high incidence in Florida. In contrast, Candida and Aspergillus species are the most common pathogens in the northern United States.

Common risk factors for the development of fungal keratitis include the following:

  • Trauma (eg, contact lenses, foreign body); in a study of fungal keratitis from south Florida, trauma with vegetable matter was the major risk factor in 44% of patients.
  • Topical corticosteroid use
  • Corneal surgery such as penetrating keratoplasty, clear cornea (sutureless) cataract surgery, or laser in situ keratomileusis (LASIK)
  • Chronic keratitis due to herpes simplex, herpes zoster, or vernal keratoconjunctivitis
  • Young males
  • Healthy
  • No significant ocular disease
  • Previous history of trauma (vegetable matter)
  • Agricultural occupations

Risk factors for Candida keratitis are as follows:

  • Older patients
  • Preexisting ocular disease
  • Exposure keratopathy
  • Chronic keratitis
  • Long-term steroid use
  • Immunosuppressive disease
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Daljit Singh, MBBS, MS, DSc  Professor Emeritis, Department of Ophthalmology, Guru Nanak Dev University, Amritsar, India; Director, Daljit Singh Eye Hospital

Daljit Singh, MBBS, MS, DSc is a member of the following medical societies: All India Ophthalmological Society, American Society of Cataract and Refractive Surgery, Indian Medical Association, International Intraocular Implant Club, and Intraocular Implant and Refractive Society, India

Disclosure: Nothing to disclose.

Coauthor(s)

Arun Verma, MD  Senior Consultant, Department of Ophthalmology, Dr Daljit Singh Eye Hospital, India

Disclosure: Nothing to disclose.

Specialty Editor Board

Anastasios J Kanellopoulos, MD  Assistant Program Director, Clinical Associate Professor, Department of Ophthalmology, Manhattan Eye, Ear, and Throat Hospital, New York University

Anastasios J Kanellopoulos, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Eye Bank Association of America, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Christopher J Rapuano, MD  Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, George Alexandrakis, MD, to the development and writing of this article.

References

  1. Haynes KA, Westerneng TJ, Fell JW, Moens W. Rapid detection and identification of pathogenic fungi by polymerase chain reaction amplification of large subunit ribosomal DNA. J Med Vet Mycol. Sep-Oct 1995;33(5):319-25. [Medline].

  2. Vaddavalli PK, Garg P, Sharma S, et al. Role of confocal microscopy in the diagnosis of fungal and acanthamoeba keratitis. Ophthalmology. Jan 2011;118(1):29-35. [Medline].

  3. Matsumoto Y, Murat D, Kojima T, Shimazaki J, Tsubota K. The comparison of solitary topical micafungin or fluconazole application in the treatment of Candida fungal keratitis. Br J Ophthalmol. Oct 2011;95(10):1406-9. [Medline].

  4. Accensi F J, Cano L, Figuera, ML Abarca and FJ. Cabañes. New PCR methods to differentiate species in the Aspergillus niger aggregate. FEMS Microbiol. Lett. 1999;180:191-196.

  5. Alexandrakis G, Jalali S, Gloor P. Diagnosis of Fusarium keratitis in an animal model using the polymerase chain reaction. Br J Ophthalmol. Mar 1998;82(3):306-11. [Medline].

  6. Avunduk AM, Beuerman RW, Varnell ED, Kaufman HE. Confocal microscopy of Aspergillus fumigatus keratitis. Br J Ophthalmol. Apr 2003;87(4):409-10. [Medline].

  7. Borne MJ, Elliott JH, O'Day DM. Ocular fluconazole treatment of Candida parapsilosis endophthalmitis after failed intravitreal amphotericin B. Arch Ophthalmol. Oct 1993;111(10):1326-7. [Medline].

  8. Chen YC, Eisner JD, Kattar MM, Rassoulian-Barrett SL, LaFe K, Yarfitz SL, et al. Identification of medically important yeasts using PCR-based detection of DNA sequence polymorphisms in the internal transcribed spacer 2 region of the rRNA genes. J Clin Microbiol. Jun 2000;38(6):2302-10. [Medline].

  9. Chowdhary A, Singh K. Spectrum of fungal keratitis in North India. Cornea. Jan 2005;24(1):8-15. [Medline].

  10. Donnenfeld ED, Perry HD, Snyder RW, Moadel R, Elsky M, Jones H. Intracorneal, aqueous humor, and vitreous humor penetration of topical and oral ofloxacin. Arch Ophthalmol. Feb 1997;115(2):173-6. [Medline].

  11. Driebe WT Jr, Mandelbaum S, Forster RK, Schwartz LK, Culbertson WW. Pseudophakic endophthalmitis. Diagnosis and management. Ophthalmology. Apr 1986;93(4):442-8. [Medline].

  12. Dunlop AA, Wright ED, Howlader SA, Nazrul I, Husain R, McClellan K. Suppurative corneal ulceration in Bangladesh. A study of 142 cases examining the microbiological diagnosis, clinical and epidemiological features of bacterial and fungal keratitis. Aust N Z J Ophthalmol. May 1994;22(2):105-10. [Medline].

  13. Einsele H, Hebart H, Roller G, Löffler J, Rothenhofer I, Muller CA. Detection and identification of fungal pathogens in blood by using molecular probes. J Clin Microbiol. Jun 1997;35(6):1353-60. [Medline].

  14. Esteve-Zarzoso B, Belloch C, Uruburu F, Querol A. Identification of yeasts by RFLP analysis of the 5.8S rRNA gene and the two ribosomal internal transcribed spacers. Int J Syst Bacteriol. Jan 1999;49 Pt 1:329-37. [Medline].

  15. Ferrer C S, Frases F, Colom, J L Alio, J L Abad, and M E. Mulet. Molecular diagnosis of fungal ocular infections in an animal model. Rev. Iberoam. Micol. 2000;17:S134.

  16. Florakis GJ, Moazami G, Schubert H, Koester CJ, Auran JD. Scanning slit confocal microscopy of fungal keratitis. Arch Ophthalmol. Nov 1997;115(11):1461-3. [Medline].

  17. Forster RK, Abbott RL, Gelender H. Management of infectious endophthalmitis. Ophthalmology. Apr 1980;87(4):313-9. [Medline].

  18. Garg P, Mahesh S, Bansal AK, Gopinathan U, Rao GN. Fungal infection of sutureless self-sealing incision for cataract surgery. Ophthalmology. Nov 2003;110(11):2173-7. [Medline].

  19. Guzek JP, Roosenberg JM, Gano DL, Wessels IF. The effect of vehicle on corneal penetration of triturated ketoconazole and itraconazole. Ophthalmic Surg Lasers. Nov 1998;29(11):926-9. [Medline].

  20. Hidalgo JA, Alangaden GJ, Eliott D, Akins RA, Puklin J, Abrams G. Fungal endophthalmitis diagnosis by detection of Candida albicans DNA in intraocular fluid by use of a species-specific polymerase chain reaction assay. J Infect Dis. Mar 2000;181(3):1198-201. [Medline].

  21. Jaeger EE, Carroll NM, Choudhury S, Dunlop AA, Towler HM, Matheson MM, et al. Rapid detection and identification of Candida, Aspergillus, and Fusarium species in ocular samples using nested PCR. J Clin Microbiol. Aug 2000;38(8):2902-8. [Medline].

  22. Jordan JA. PCR identification of four medically important Candida species by using a single primer pair. J Clin Microbiol. Dec 1994;32(12):2962-7. [Medline].

  23. Kauffman CA, Bradley SF, Vine AK. Candida endophthalmitis associated with intraocular lens implantation: efficacy of fluconazole therapy. Mycoses. Jan-Feb 1993;36(1-2):13-7. [Medline].

  24. Keyhani K, Seedor JA, Shah MK, Terraciano AJ, Ritterband DC. The incidence of fungal keratitis and endophthalmitis following penetrating keratoplasty. Cornea. Apr 2005;24(3):288-91. [Medline].

  25. Knox CM, Cevellos V, Dean D. 16S ribosomal DNA typing for identification of pathogens in patients with bacterial keratitis. J Clin Microbiol. Dec 1998;36(12):3492-6. [Medline].

  26. Kumar M, Shukla PK. Use of PCR targeting of internal transcribed spacer regions and single-stranded conformation polymorphism analysis of sequence variation in different regions of rrna genes in fungi for rapid diagnosis of mycotic keratitis. J Clin Microbiol. Feb 2005;43(2):662-8. [Medline].

  27. Lott TJ, Kuykendall RJ, Reiss E. Nucleotide sequence analysis of the 5.8S rDNA and adjacent ITS2 region of Candida albicans and related species. Yeast. Nov 1993;9(11):1199-206. [Medline].

  28. Mabon M. Fungal keratitis. Int Ophthalmol Clin. 1998;38(4):115-23. [Medline].

  29. Makimura K, Murayama SY, Yamaguchi H. Detection of a wide range of medically important fungi by the polymerase chain reaction. J Med Microbiol. May 1994;40(5):358-64. [Medline].

  30. Miyakawa Y, Mabuchi T, Kagaya K, Fukazawa Y. Isolation and characterization of a species-specific DNA fragment for detection of Candida albicans by polymerase chain reaction. J Clin Microbiol. Apr 1992;30(4):894-900. [Medline].

  31. Okhravi N, Adamson P, Mant R, Matheson MM, Midgley G, Towler HM. Polymerase chain reaction and restriction fragment length polymorphism mediated detection and speciation of Candida spp causing intraocular infection. Invest Ophthalmol Vis Sci. May 1998;39(6):859-66. [Medline].

  32. Panda A, Sharma N, Das G, Kumar N, Satpathy G. Mycotic keratitis in children: epidemiologic and microbiologic evaluation. Cornea. May 1997;16(3):295-9. [Medline].

  33. Prajna NV, John RK, Nirmalan PK, Lalitha P, Srinivasan M. A randomised clinical trial comparing 2% econazole and 5% natamycin for the treatment of fungal keratitis. Br J Ophthalmol. Oct 2003;87(10):1235-7. [Medline].

  34. Prajna NV, Nirmalan PK, Mahalakshmi R, Lalitha P, Srinivasan M. Concurrent use of 5% natamycin and 2% econazole for the management of fungal keratitis. Cornea. Nov 2004;23(8):793-6. [Medline].

  35. Reiss E, Tanaka K, Bruker G, Chazalet V, Coleman D, Debeaupuis JP. Molecular diagnosis and epidemiology of fungal infections. Med Mycol. 1998;36 Suppl 1:249-57. [Medline].

  36. Riggsby WS, Torres-Bauza LJ, Wills JW, Townes TM. DNA content, kinetic complexity, and the ploidy question in Candida albicans. Mol Cell Biol. Jul 1982;2(7):853-62. [Medline].

  37. Rosa RH Jr, Miller D, Alfonso EC. The changing spectrum of fungal keratitis in south Florida. Ophthalmology. Jun 1994;101(6):1005-13. [Medline].

  38. Srinivasan M. Fungal keratitis. Curr Opin Ophthalmol. Aug 2004;15(4):321-7. [Medline].

  39. Tang CM, Holden DW, Aufauvre-Brown A, Cohen J. The detection of Aspergillus spp. by the polymerase chain reaction and its evaluation in bronchoalveolar lavage fluid. Am Rev Respir Dis. Nov 1993;148(5):1313-7. [Medline].

  40. Thomas PA. Fungal infections of the cornea. Eye. Nov 2003;17(8):852-62. [Medline].

  41. Upadhyay MP, Karmacharya PC, Koirala S, Tuladhar NR, Bryan LE, Smolin G. Epidemiologic characteristics, predisposing factors, and etiologic diagnosis of corneal ulceration in Nepal. Am J Ophthalmol. Jan 15 1991;111(1):92-9. [Medline].

  42. Weissgold DJ, Orlin SE, Sulewski ME, Frayer WC, Eagle RC Jr. Delayed-onset fungal keratitis after endophthalmitis. Ophthalmology. Feb 1998;105(2):258-62. [Medline].

  43. White TJ, Bruns T, Lee S, Tailor S. Amplification and direct sequencing of fungal ribosomal RNA genes for phylogenetics. In: Innins MA, Gelfand DH, Sninsky JJ, White TJ, eds. PCR Protocols. A Guide to Methods and Applications. San Diego, CA: Academic Press, Inc; 1990:315-22.

 
Previous
Next
 
Fungal corneal ulcer.
Perforated fungal ulcer.
Fungal infection under treatment.
Perforated fungal corneal ulcer.
Fungal ulcer in an elderly woman.
Fungal ulcer.
Fungal corneal ulcer, with excessive vascularization.
Marginal ulcer, fungus positive.
Healed fungal ulcer.
Fungal keratitis.
Corneal perforation, blocked by a crystalline lens and being covered by epithelium.
Fungal keratitis, being controlled.
Fungal infection.
Fungal infection.
Fungal abscess.
Fungal corneal abscess/ulcer. A proven case of fungal infection, 5 days' duration. Intense infiltration around the abscess.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.