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Recognition, diagnosis, and management of fungal keratitis remain difficult despite significant advances in our understanding of the disease.1–4
We report three cases secondary to corneal foreign body which were managed at Manchester Royal Eye Hospital (MREH)
Case reports
Case 1
A 22 year old man presented to MREH with a metallic corneal foreign body that was removed; chloramphenicol eye drops were prescribed.
He returned 3 days later with pain, hand movement vision, a round corneal ulcer, and a hypopyon. A corneal scrape was performed and he was treated with intensive topical antibiotics. The Gram stain showed few fungal hyphae which were thought to be contaminants. The patient was reviewed by the corneal service 6 days after his injury. As the patient was clinically improving, the antibiotic treatment was continued.
On day 7 a scanty growth of Aspergillus fumigatus was reported. The topical antibiotics were discontinued and he was started on miconazole eye drops 1% hourly.
The ulcer continued to heal slowly and at final review 1 month later vision was 6/9.
Case 2
A metallic corneal foreign body was removed from a 53 year old man; he was treated with chloramphenicol eye drops.
Two days later he developed a corneal ulcer with a hypopyon which was scraped and treated with intensive topical antibiotics. The corneal scrape showed a scanty growth of Aspergillus fumigatus. He was commenced on amphotericin eye drops 0.15% hourly and antibiotics were discontinued.
He was referred to MREH 23 days after his injury with no improvement (fig 1A). A second corneal scrape was performed which showed hyphal fragments on the Gram stain. Oral intraconazole 200 mg three times daily was added to treatment.
(A) Central corneal ulcer with diffuse stromal infiltration and hypopyon in case 2. (B) Central corneal ulcer with hypopyon in case 3.
In view of the deteriorating clinical condition a penetrating keratoplasty was performed and amphotericin (7.5 μg) was given intracamerally. Aspergillus fumigatus was present in the corneal button with a clear edge. Thirty months after surgery his best corrected vision was 6/6.
Case 3
A metallic corneal foreign body was removed in casualty from a 46 year old man; he was treated with chloramphenicol eye drops.
Two days later, he presented with increasing pain, hand movement vision, and a corneal ulcer which was scraped. The Gram stain showed a few inflammatory cells. The patient failed to respond to intensive topical antibiotics.
Aspergillus fumigatus was reported and he was treated with hourly natamycin and clotrimazole eye drops, and oral fluconazole 200 mg twice daily. On day 23 fluconazole was discontinued and itraconazole 200 mg twice daily was commenced.
The patient was referred to MREH corneal service 29 days after his injury with no change in the clinical picture (fig 1B). The cornea was rescraped confirming presence of aspergillus infection. Topical treatment was changed to amphotericin eye drops and oral itraconazole was increased to three times daily.
Finally, a penetrating keratoplasty was performed with intracameral amphotericin-B (7.5 μg). Aspergillus fumigatus was present in the corneal button with a clear edge.
Phacoemulsification and lens implantation were carried out 2 months after the graft. Thirty months after keratoplasty the graft remained clear with 6/18 vision.
Comment
Most fungal keratitis is caused by filamentous fungi with the epidemiology varying throughout the world.1,5–7 It is believed to be rare in Britain especially after injury with a metallic foreign body. Our cases demonstrate the difficulties in establishing a diagnosis by culture. Two patients required a therapeutic keratoplasty, which eliminates 90–100% of fungal infections.8 In recent reports intracameral amphotericin has been used,9 as part of the medical treatment which may prove useful if aspergillus keratitis becomes more common in the Britain.