Fungal Keratitis

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Findings

  • Typical features of fungal keratitis: infiltrate with elevated edges, feathery infiltrate, satellite lesions, may have hypopyon, fibrin in the anterior chamber less common
    • Caution: clinical differentiation between fungal keratitis and bacterial keratitis not (reliably) possible!
  • Think of fungal infection in case of injury with organic material

Work-up

  • Photo documentation
  • Corneal specimen collection (as for bacterial keratitis)
    • PCR, culture for bacteria + fungi, direct examination by microscopy
    • consider sending in contact lenses
  • Consider corneal biopsy
  • Confocal microscopy: hyphae?

Management

  • Initial therapy if fungal keratitis is suspected
    • Amphotericin B 0.5% gtt 2-hourly and Floxal gtt 5x/d
    • alternatively: Amphotericin B 0.5% gtt and Ceftazidim/Ofloxacin (compounded gtt) 2-hourly alternating (as bacterial superinfection is frequent)
    • At the beginning of therapy, consider performing a corneal abrasion to increase drug penetrance (repeat if necessary)
  • In case of a (suspected) Candida infection
    • Amphotericin B 0.15% gtt or Voriconazole 2% gtt initially 2-hourly to hourly for 48h, then reduce depending on the course
  • In case of filamentous fungi (aspergillus, fusaria):
    • Natamycin 5% every 2h, requires approval of health insurance
  • Systemic antimycotics may be necessary in severe keratitis, limbal lesions or suspected endophthalmitis:
    • e.g. Voriconazole p.o. 400mg 2x/d for 1 day, then 200mg 2x/d
      • CAVE: check liver function before and during therapy
  • Consider Scopolamine 0.25% gtt 2x/d for (severe) anterior chamber cells/flare, (also relieves pain due to cycloplegia).
  • Consider Tetracycline systemically (e.g. Doxycycline 100mg 2x/d) in case of significant corneal thinning (inhibits collagenase activity).

Follow-up

  • Initially, daily follow-up until clinical improvement
  • Inpatient admission often necessary (especially in the case of severe findings and problems with therapy adherence)
  • CAVE: most antimycotics only have a fungistatic effect: maintain therapy for at least 12 weeks!

Sources

  • EyeWiki Fungal Keratitis
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)