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In vivo confocal microscopy appearance of Fusarium and Aspergillus species in fungal keratitis
  1. Jaya Devi Chidambaram1,
  2. Namperumalsamy Venkatesh Prajna2,3,
  3. Natasha Larke4,
  4. David Macleod4,
  5. Palepu Srikanthi2,
  6. Shruti Lanjewar2,
  7. Manisha Shah2,3,
  8. Prajna Lalitha2,3,
  9. Shanmugam Elakkiya2,3,
  10. Matthew J Burton1
  1. 1International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
  2. 2Aravind Eye Hospital, Madurai, Tamil Nadu, India
  3. 3Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
  4. 4Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Dr Jaya D Chidambaram, International Centre for Eye Health, London School of Hygiene & Tropical Medicine, Room K390, Keppel Street, London WC1E 7HT, UK; Jaya.Chidambaram{at}


Background Clinical outcomes in fungal keratitis vary between Fusarium and Aspergillus spp, therefore distinguishing between species using morphological features such as filament branching angles, sporulation along filaments (adventitious sporulation) or dichotomous branching may be useful. In this study, we assessed these three features within Heidelberg Retina Tomograph 3 in vivo confocal microscopy (IVCM) images from culture-positive Fusarium and Aspergillus spp keratitis participants.

Methods Prospective observational cohort study in Aravind Eye Hospital (February 2011–February 2012). Eligibility criteria: age ≥18 years, stromal infiltrate ≥3 mm diameter, Fusarium or Aspergillus spp culture-positive. Exclusion criteria: previous/current herpetic keratitis, visual acuity <6/60 in fellow eye, >80% corneal thinning. IVCM was performed and images analysed for branch angle, presence/absence of adventitious sporulation or dichotomous branching by a grader masked to the microbiological diagnosis.

Results 98 participants were included (106 eligible, 8 excluded as no measurable branch angles); 68 were positive for Fusarium spp, 30 for Aspergillus spp. Mean branch angle for Fusarium spp was 59.7° (95% CI 57.7° to 61.8°), and for Aspergillus spp was 63.3° (95% CI 60.8° to 65.8°), p=0.07. No adventitious sporulation was detected in Fusarium spp ulcers. Dichotomous branching was detected in 11 ulcers (7 Aspergillus spp, 4 Fusarium spp).

Conclusions There was very little difference in the branching angle of Fusarium and Aspergillus spp. Adventitious sporulation was not detected and dichotomous branching was infrequently seen. Although IVCM remains a valuable tool to detect fungal filaments in fungal keratitis, it cannot be used to distinguish Fusarium from Aspergillus spp and culture remains essential to determine fungal species.

  • Cornea
  • Imaging
  • Infection
  • Microbiology
  • Diagnostic tests/Investigation

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  • Contributors Conception and design: JDC, NVP, NL, MJB. Data acquisition: JDC, PS, SL, MS, PL, SE. Data analysis/interpretation: JDC, NL, DM, MJB. Manuscript preparation: JDC, DM, MJB. Manuscript critical revision/approval of final version: all authors. All authors agree to be accountable for all aspects of the work and will ensure that any questions that may arise related to the accuracy or integrity of any part of the work will be appropriately investigated and resolved.

  • Funding This work was supported by the Wellcome Trust grant no. 097437/Z/11/Z to JDC.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Ethics Committees of London School of Hygiene and Tropical Medicine, Aravind Eye Hospital and Indian Council for Medical Research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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