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Fungal Keratitis Follow-up

  • Author: Daljit Singh, MBBS, MS, DSc; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: May 20, 2015
 

Further Outpatient Care

Most patients with fungal keratitis are treated on an outpatient basis.

Antifungal therapy generally should be maintained for 12 weeks with routine follow-up examinations.

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Further Inpatient Care

Indications for inpatient care include clinical evidence of an impending corneal perforation or if the patient is unable to administer frequent eye drops. In such cases, inpatient care includes topical fortified antifungal therapy administered every hour around the clock with frequent monitoring for any signs of corneal perforation.

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Inpatient & Outpatient Medications

The medications prescribed depend on the specific etiologic agent identified in cultures.

In general, amphotericin B should be prescribed to a patient presenting with a fungal ulcer suggestive of yeast infection (Candida species), and natamycin should be prescribed when a high suspicion exists for a filamentous fungus (eg, Fusarium species). Candida species are frequently more common in sick corneas, while Fusarium species are often more common after trauma.

Fluconazole or ketoconazole should be used in patients with deep stromal infection.

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Complications

Fungal keratitis can lead to severe ocular infections involving any intraocular structure and can result in severe visual loss or even loss of the eye.

Corneal perforation is not unusual, and secondary endophthalmitis has been reported.

Perforated fungal ulcer. Perforated fungal ulcer.
Perforated fungal corneal ulcer. Perforated fungal corneal ulcer.
Corneal perforation, blocked by a crystalline lens Corneal perforation, blocked by a crystalline lens and being covered by epithelium.
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Prognosis

Prognosis depends on several factors, including the extent of corneal involvement upon presentation, the patient's health status (eg, immunocompromised), and the timing of establishing a clinical diagnosis confirmed by culture in the laboratory.

Patients with mild infections and an early microbiologic diagnosis have a good prognosis; however, controlling or eradicating an infection that spreads into the sclera or the intraocular structures is very difficult.

Approximately one third of fungal infections result in either medical treatment failure or corneal perforation.

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Patient Education

Patients who wear contact lenses should consult their eye care professional concerning use of an appropriate cleaning/disinfecting product. (Patients should discontinue use of Bausch & Lomb ReNu with Moisture Lock contact lens solution.)

Patients should consider performing a “rub and rinse” lens cleaning method, rather than a no rub method, regardless of which cleaning/disinfecting solution used, in order to minimize the number of germs and to reduce the chances of infection.

Patients should continue to follow proper lens care practices. Wash their hands with soap and water and dry (lint-free method) them before handling lenses. Wear and replace lenses according to the schedule prescribed by their eye care professional. Follow the specific lens cleaning and storage guidelines from their eye care professional and the solution manufacturer. Keep the contact lens case clean and replace every 3-6 months.

Patients should remove the lenses and consult their eye care professional immediately if they experience symptoms, such as redness, pain, tearing, increased light sensitivity, blurry vision, discharge, or swelling.

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Contributor Information and Disclosures
Author

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

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

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

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Hospital

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, Allergan, Bausch & Lomb, Bio-Tissue, Shire, TearScience, TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue, TearScience.

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

George Alexandrakis, MD Consulting Staff and Surgeon, Department of Ophthalmology, Southern California Permanente Medical Group

George Alexandrakis is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

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.

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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.
Surgical trauma producing edema and striate keratitis. The corneal channels stand out in semiopaque corneal tissue, since they themselves are no-tissue spaces.
Surgical trauma producing edema and striate keratitis. The corneal channels stand out in semiopaque corneal tissue, since they themselves are no-tissue spaces.
A network of channels is visible in a case of megalocornea with faint opacification of stroma. The channels stand out as nonstructures.
This kind of opacification is termed keratitis. Anatomically, it appears to be a microchannel structure.
A network of corneal channels stands out inside the arcus senilis of an old patient. Whatever causes the opacification in the corneal tissue is not able to opacify the emptiness of corneal channels.
Network of corneal channels in a 92-year-old patient.
The corneal channels open in the lucid interval channel of Singh.
Peripheral corneal channel network and canal of Singh in 3 dimensions.
Optical section of corneal channels in a case of arcus senilis.
The lucid interval in optical section clearly shows its triangular configuration and an anterior and posterior wall. The apex continues towards corneal channels in the stroma. The lucid interval channel is connected to limbal lymphatics.
The lucid interval channel is connected to the lymphatics at the limbus and the corneal channels centrally.
A blunt wire of 100 micrometers diameter has been pushed into the canal of Singh.
A 230-micrometer blunt cannula in the canal of Singh.
This networklike pattern of fungal corneal infection is explained only by the preferential path of spread through the corneal channel network.
The fungal infection travels in various directions. Also seen are satellite lesions. Satellite lesions and other appearances are explained by the presence of channels in the cornea.
Notice centrifugal, linear, circular, and satellitelike spread of fungal infection through the corneal channels.
This patient presented with infection of the lucid interval of Singh without any evidence of corneal ulceration as a starting point, suggesting systemic spread. A satellite of infection is seen near the 6-o'clock position.
Same patient with infection of the lucid interval of Singh without any evidence of corneal ulceration as a starting point, suggesting systemic spread. A big and a small satellite at the 6-o'clock position.
The same eye showing the spread of fungal infection on the nasal side of the Singh canal. This patient showed no evidence of corneal injury, thus a systemic origin of infection is a distinct possibility.
The whole of the infected lucid interval canal of Singh was opened. The scraping showed the presence of hyphae. The patient was treated by oral medication, local drops, and intracorneal antifungal voriconazole injections. Final vision was 6/6 uncorrected. There was no recurrence.
Optical coherence tomography scans clearly showing the canal of Singh connected to the Schlemm canal.
Optical coherence tomography scans clearly showing the canal of Singh connected to the Schlemm canal.
Fungal keratitis under treatment. The infection has spread into the nearby lucid interval canal of Singh.
The same case as in the previous photo. Optical coherence tomography scans shows the presence of exudates in the lucid interval canal of Singh and the adjoining trabecular meshwork.
 
 
 
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