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   Table of Contents      
ARTICLES
Year : 1973  |  Volume : 21  |  Issue : 2  |  Page : 51-55

Keratomycosis : A report of 23 cases


Department of Ophthalmology, Sawai Man Singh Medical College, Jaipur, India

Correspondence Address:
O P Kulshrestha
Department of Ophthalmology, Sawai Man Singh Medical College, Jaipur
India
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Source of Support: None, Conflict of Interest: None


PMID: 4789110

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How to cite this article:
Kulshrestha O P, Bhargava S, Dube M K. Keratomycosis : A report of 23 cases. Indian J Ophthalmol 1973;21:51-5

How to cite this URL:
Kulshrestha O P, Bhargava S, Dube M K. Keratomycosis : A report of 23 cases. Indian J Ophthalmol [serial online] 1973 [cited 2020 May 28];21:51-5. Available from: http://www.ijo.in/text.asp?1973/21/2/51/31412

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One of the important features causing mycotic infection is corneal injury particularly in cultivators and labourers working in the fields, where fungal spores are widely distributed the source of injury being vegetable or plant matter (GINGRICH, [8] and PUTTANNA [15] ). Other important fac­tors may be the extensive and indis­criminate use of anti-biotics and corticosteriods which may supress the bacterial flora and help in the invasion and propagation of mycotic structures (LEY AND SANDERS [11] , BARSKEY [4] , AGARWAL AND KHOSLA [2] ).

An unselected group of 52 cases of corneal ulcers admitted to the eye ward of The General Hospital, Udaipur, have been investigated for the occurance of fungus infection of the cornea. Most of the patients admitted were farmers from surround­ing areas with rather a poor economic status.

A detailed laboratory study was done. The corneal scraping material was inoculated on to a bottle of Sabouraud's media and corn-meal agar. These were incubated at room temperature for a period of 3 weeks to 6 weeks. The growth of fungus was obtained within 4 days to 14 days and cultures were discarded after 45 days.

The fungi were isolated and identifi­ed by the study of growth characteris­tics, biochemical reactions and micro­scopic features, e.g., mycelia, spores and conidia by wet preparation in Lactophenol-blue solution (Conant et al [5] ).


  Results Top


Out of 52 cases of corneal ulcers, direct examination of scrapings taken from the margin of the ulcers revealed the presence of mycelia in 10% KOH preparation only in 5 cases. While on culture examination, fungus flora were isolated in 23 cases giving an incidence of 44.3% of keratomycosis.

As far as the incidence of type of fungus is concerned, Aspergillus species indicated the highest incidence (6 cases), but an interesting observa­tion was the isolation of Dermatophytes from the corneal ulcers. The most important clinical feature recorded was the presence of hypopyon in 14 cases out of 23 cases of mycotic infection, while satellite lesions were observed in four cases.

Many agents and procedures includ­ing keratoplasty were used for the treatment of such cases. Keratoplasty was performed in 4 cases (in 3 cases, penetrating and lamellar graft in one).

In three cases a corneal graft was successful while in one case, where it was unsuccessful, Aspergillus was found to be the causative organism. In the latter case, the graft slowly denoted infiltration followed by slough­ing of the donor corneal tissue due to the fungus infection and evisceration had to be done.

In three successful cases, Asper­gillus was grown from one eye in which a penetrating corneal graft saved the eye although the graft ultimately became opaque. Rhizopus was grown in a second case and after therapeutic lamellar graft the cornea became clear. In the third case, culture proved the presence of Asper­gillus and a good result was obtained after therapeutic penetrating kerato­plasty.


  Discussion Top


Mycotic infections usually begin after some corneal injury. Alter­natively , mycotic infection may develop in an eye where an epithelial lesion already exists as in Herpes (DUKE ELDER AND LEIGH [7] ). We found corneal involvement by Herpes Zoster in one case and Aspergillus was the secondary invader in this case.

Aspergillus has been isolated from corneal ulcers in India by BALKRISHNA [3] PUTTANNA [13] AND SOOD, RATNARAJ, SHANEY AND MADHAVAN [17] . In the present study Aspergillus was grown on culture in eight cases, hypopyon being present in five of these cases.

The incidence of Dermatophyton isolated may be correlated with the high incidence of superficial dermato­phytes in this part of the country (DUBE, GUPTA AND SOGANI [6] ). We found one case of Tricophyton, two of Epidermophyton and-one of Micro­sporum but without skin infection. MITSUI AND HANABUSA [12] cultured Tricophyton from a normal conjunc­tival sac in a series of 65 normal control eyes. The fungus belonging to the Genus Tricophyton, produces ring worm of the skin, a common infection in this part of India. When the skin around the eye is already affected, ring worm may occasionally invade the conjunctiva and produce conjunctivitis (GROVER, 1961). Conjunctivitis may also occur in asso­ciation with Tricophytic infection of the scalp and may spread to the cornea.

In one case of corneal ulcer with a positive history of injury, Trico­phyton species of fungi was cultured.

No skin infection was noticed. Trico­phyton being a normal inhabitant of the conjunctiva, the corneal ulcer might have been produced when the epithelium was denuded due to injury.

Epidermophyton was isolated from two cases. One case had a history of injury with a finger-nail with the presence of hypopyon and dry slough. The other case had a pre-existing band shaped keratopathy.

Microsporum was isolated in one patient and on repeating the culture Microsporum was grown again.

Mucor is considered a very rare cause of mycotic corneal ulcer as the reports in the literature are very few. VEIRS AND DAVIS [18] reported two cases of fungusinfection of the cornea and mucor was found on a histopatho­logical examination. We encountered one case of mucor infection of cornea having a severe corneal infection. Hypopyon was present in whole of the anterior chamber and the ulcer perforated. Panophthalmitis develop­ed during the course of infection and evisceration was made.

Rhizopus which is considered to be one of the common contaminants (CONANT et al. 1954) has been shown to produce keratitis in experimental animals (PUTTANNA, 1964). In the present study, three cases were owing to Rhizopus which may be pathogenic in the tissues having a poor blood supply.

Candida infection is usually as a result of transmission of infection by way of trauma and infection may be aggravated when steroid therapy is used. In our three cases of candida albicans infection, there was a history of direct trauma and also it had hypopyon.

PUTTANNA from India (1967) re­ported two cases of Penicillium species out of 20 cases of mycotic keratitis. We have obtained Penicillium in two cases out of 23 cases of mycotic keratitis.

The presence of fungi in 23 cases out of 52 cases of corneal ulcers do not represent the true incidence of fungusinfection in all cases of corneal ulcers. These were the cases of severe corneal ulceration which could not properly be treated in the Out-patients' Department and needed admission to the hospital.


  Summary Top


Fifty two cases of corneal ulcers were investigated for mycotic infection. Mycotic flora was grown on culture in 23 cases. The species isolated were Aspergillus (8 cases), Candida (3 cases), Rhizopus (3 cases), Dermatophytes (4 cases), Yeast (2 cases), Penicillum (2 cases) and Mucor (1 case). History of injury was recorded in 17 cases.


  Acknowledgement Top


The authors are thankful to Dr. O. P. Gupta, Prof. of Pathology for help in the isolation of the fungi and useful suggestions.

 
  References Top

1.
Agarwal, L. P., Malik, S. R. K., Mohan, M., Khosla, P. K.: Mycotic corneal ulcer. Brit. Jr. Ophthal. 47: 109 (1963).  Back to cited text no. 1
    
2.
Agarwal, L. P. and Khosla, P. K.: Mycotic keratitis (experimental and clinical study): J. All Ind. Ophthal. Soc. 15: 1 (1967).  Back to cited text no. 2
    
3.
Balakrishna, E.: Mycotic keratitis caused by Aspergillus Fumigatus.: Brit. Jr. Ophthal. 45: 828 (1961).  Back to cited text no. 3
    
4.
Barskey, D.: Keratomycosis. A. M. A. Arch. Ophth., 61: 547 (1959).  Back to cited text no. 4
    
5.
Conant, N. R., Smith, D. T., Baker, R. D., Callaway, J. L. and Martin, D. S.: Manual of clinical Mycology. 2nd Ed. Saunders. Philadelphia (1954).  Back to cited text no. 5
    
6.
Dube, N. K., Gupta, O. P. and Sogani, R. K.: A study of superficial Mycosis in Udaipur. Presented at XVIII Annual meeting of Ind. Assoc. of Pathologists (1968).  Back to cited text no. 6
    
7.
Duke Elder, S. and Leigh, A. G.: System of Ophthalmology, Vol. VIII, Part II. Diseases of outer eye. Henry Kimpton London (1965).  Back to cited text no. 7
    
8.
Gingrich, W. D.: Keratomycosis. J. A. M. A., 179: 602 (1962).  Back to cited text no. 8
    
9.
Grover, A. D. and Agarwal, K. C.: Mycotic keratitis. Brit. Jr. Ophthal. 45: 824 (1961).  Back to cited text no. 9
    
10.
Halde, C. and Okumoto, M.: Ocular Mycosis. XX Concillium Ophthal­mologicum Germania. Acta Part 11, 705-712 (1966).  Back to cited text no. 10
    
11.
Ley, A. P. and Sanders, T. E.: Fungus keratitis (A report of 3 cases): A. M. A. Arch. Ophth. 56: 257 (1956).  Back to cited text no. 11
    
12.
Mitsui, Y. and Hanabusa, J.: Corneal infection after cortisone therapy. Brit. Jr. Ophth. 39: 244 (1955).  Back to cited text no. 12
    
13.
Puttanna, S. T.: Primary Fungus Keratitis. Trans. 1st Cong. Asia­ Pacific Acad. Ophth., 471 (1960).  Back to cited text no. 13
    
14.
Ibid: Primary Fungus Keratitis after instillation of herbal juice as part of native treatment. Trans. 2nd Cong. Asia - Pacific Acad. Ophth. (1964).  Back to cited text no. 14
    
15.
Ibid: Mycotic infection of the cornea: J. All Ind. Ophth. Soc., 15: 11 (1967).  Back to cited text no. 15
    
16.
Ibid: Primary Keratomycosis. J. All Ind. Ophthat. Soc. 17: 171 (1969).  Back to cited text no. 16
    
17.
Sood, N. N., Ratnaraj, A., Shaney, B. P. and Madhavan, H. N.: Hypopyon ulcers: Clinical study. Orient Arch. Ophth. 6: 100 (1968).  Back to cited text no. 17
    
18.
Veirs, E. R. and Davis, C. T.: Fungus infection of the eye and the orbit. A. M. A. Arch. Ophth. 59: 172 (1958).  Back to cited text no. 18
    


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