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ARTICLES |
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Year : 1978 | Volume
: 26
| Issue : 1 | Page : 9-11 |
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Treatment of keratomycosis with amphotericin B. ointment
MR Chaddah, DC Aggarwal
Medical College, Amritsar-Punjab, India
Correspondence Address: M R Chaddah Department of Ophthalmology, Medical College, Amritsar-Punjab India
Source of Support: None, Conflict of Interest: None | Check |
PMID: 711284
How to cite this article: Chaddah M R, Aggarwal D C. Treatment of keratomycosis with amphotericin B. ointment. Indian J Ophthalmol 1978;26:9-11 |
Mycotic corneal ulcers are becoming more frequent due to increasing use of broad spectrum antibiotics and corticosteroids. In the literature there are a number of reports regarding the efficacy of topical use of various antimycotic agents. Kaufman and Wood[1] found thiomersal (Merthiolate in dil. of 1 : 1000 in normal saline) as disappointing, whereas Jones et al[1] reported that 5% suspension of Pimaricin is effective against Fusarium solani keratitis only.
Amphotericin B is the only anti-fungal antibiotic which is effective against wide variety of mycotic lesions of cornea.[2] It is an antifungal antibiotic which was isolated in 1955 by Gold et al[7] from a soil strain of streptomyces originating in Venezuela. Jones et al[1] and Wood and Williford[15] have tried amphotericin B in the form of aqueous solutions with encouraging results. However, we have not come across any report from this country regarding use of amphotericin ointment in keratomycosis.
Material and Methods | | |
Cultures were done in twenty cases of corneal ulcers which had the clinical appearance of fungal keratitis. Scrapings from corneal ulcers which presented with characteristics of fungal infection were examined for the presence of hyphae and were also cultured on Sabouraud's agar medium. In addition to usual treatment of corneal ulcer 10% amphotericin ointment was put in the eye twice a day. The response to treatment was noted daily.
Observations | | |
Sixty percent of the patients gave a history of trauma out of whom 60% had agricultural injury. Corneal ulcers were central in 14 patients (70%) whereas in others they were either paracentral or peripheral. Dry yellowish slough was present in 16 cases (80%). Twelve patients (60%) had used both corticosteroids and antibiotics locally whereas one had used steroids only and the remaining did not use any medicine.
Culture reports were as under:
Aspergillus 12%
Aspergillus and Epidermophyton I%
Aspergillus Paecilomyces 1%
Penicillium 1%
Hemispora 1 %
Epidermophyton 1%
Fusarium 1%
No Growth. 2%
The first detectable improvement in ulcer was rounding up of the irregular margins accompanied by decrease in the congestion within 2-3 days. This was accompanied by subjective improvement of symptoms which were followed by re-epithelization. In 14 cases ulcers healed after treatment for 2'2 weeks to 5 weeks, average being 3J weeks. In the remaining 6 cases the drug was ineffective and conjunctival flapping had to be done. In patient in whom the ulcer healed with this treatment the resultant visual acuity was not encouraging. All these patients tolerated the drug and did not have ocular irritation.
Discussion | | |
Forty per cent of our patients were agricultural labourers whereas in cases reported by Balakrishnan[3], 30% were agricultural labourers History of trauma was available in 60% of the cases whereas in non-fungal ulcers studied in this department the history of trauma was present in 47% of the patients only. Thus traumatizing agents infected in the fields may be an important etiological factor in producing keratomycosis. According to Anderson et al[2] the commonest initial cause of fungal corneal ulcers is trauma due to variety of accidental injuries such as vegetable matter, soil, bush or machine tools.
In the present study the mycological identification by culture was positive in 90% of the cases as compared to 85.7%[4] and 65.6%[15].
Aspergillus constituted the major causative agent (70%) in our cases. In India the prevalence of Aspergillus has been reported to be 50%[14] and 54%[6]. Aspergillus has been reported to be second commonest invader in South Florida[10], Britain[1] and Nigeria[8] whereas Fusarium is considered to be commonest fungus in South Florida[9] and Nigeria[8].
Amphotericin B has been used by various workers in aqueous form, alone or in combination with other antifungal drugs with varying result. Currie[5] used this drug in dilution of 1 mg per ml in three cases of Keratomycosis, with quick, complete and dramatic results. But in two out of the three cases, there was severe pain for 5 minutes after each instillation. Jones et al[10] used pimaricin in 16 out of 28 cases of Fusarium keratitis and suggested that 5% pimaricin should be the initial therapy followed by the use of amphotericin B. Polak and Kaufman[13] treated 33 cases of keratomycosis successfully with combined application of 5% pimaricin and amphotericin B in 0.5% aqueous form. Chin et all used amphotericin B in 0.5% aqueous form and pimaricin 5%. According to him pimaricin is effective in candida infection.
In this study amphotericin B ointment in concentration of 10% was used twice daily. The drug was used for a minimum period of 22 weeks to a maximum of 5 weeks for complete cure of the ulcer whereas Anderson et a[2]' used the drug in aqueous form for a minimum period of 4 months to a maximum of 9 months for complete cure of ulcer. Kaufman and Wood[12] also made similar observations.
The visual results in our series were not as good as reported by Wood and Williford[15] which could be due to the fact that our patients reported late.
The disadvantage with the use of amphotericin B in aqueous form is that a concentration of 0.3% or more have not been well tolerated and therefore poor response to treatment. Secondly, the intolerance is due to ocular irritation from sodium desoxycholate which is added to make amphotericin B water soluble in concentration of 0.3% or more.[11]
The advantage with amphotericin ointment is that it could be used in a greater strength of 10% without any ocular irritation. The second advantage with amphotericin B ointment is that it adhered to the ulcer surface leading to prolonged contact time and did not get diluted with the tears. It was well tolerated and did not produce any ocular irritation which has been reported after the use of aqueous solution.
This study suggests that amphotericin B ointment is quite effective in the treatment of Keratomycosis and should be the initial drug of choice.
Summary and Conclusion | | |
Aspergillus was the most common fungus responsible for mycotic keratitis in our series. Ten per cent amphotericin B ointment was quite effective in the treatment of keratomycosis. The drug was well tolerated and did not produce any ocular irritation.
References | | |
1. | Ainley, R., Smith, B., 1965, Brit. J. Ophthal., 49, 505. |
2. | Anderson, B., Robert, S., Gonalez, C. and Chick, E., 1959, Arch. Ophthal., 62, 169. |
3. | Balakrishnan, E., 1962, XIX International Ophthalrnological Congress, Ophthalmological Acta. 11, 1242. |
4. | Chin, G.N., Hyndink, R.A., Kwasmy, G.P. and Schultz, R.O., 1975, Amer. J. Ophthal., 79, 121. |
5. | Currie, D., 1963, Arch. Ophthal., 70, 335. |
6. | Das Gupta, L.R., Gup:a, A.K., Ray Ghosh, B., Sundararaj, I., Ramamurthy, S. and Lamba, P.A., 1973, Indian J. Med. Res., 61, 165. |
7. | Gold, W., Stout, H.A., Pagano, J.F. and Donovick, R. 1956, Quoted by Foster, J B.T., Almeda, E., Littman, M.L., Wilson M.E., 1958, AMA. Arch. Ophthal., 60, 555. |
8. | Gugnani, H.C., Talwar, R.S., Njokyobi, A.N.U. and Kodilinye, H.C., 1976, Brit. J. O,-:hthal., 60,607. |
9. | Jones, B.P., Jones, B.D., Lun, A.S.M., Bron, A.J., Movgen, G. and Clayton, Y.M., 1969, Trans. Ophthal. Soc., U.K. 89,757. |
10. | Jones, D.B., Sexton, R.R. and Rebell, G.G., 1969, Trans. Ophthal. Soc., U.K., 89, 781. |
11. | Jones, D.B., Foster, R.R. and Rebell, 1972, Arch. Ophthal., 88, 147. |
12. | Kaufman, H.E. and Wood R.M., 1965, Amer. J. Ophthal., 59, 993. |
13. | Polak, E.M. and Kaufman, H.E., 1971, Arch. Ophthal., 85, 410. |
14. | Reddy, P.S., Satyendran, O.M., Satapathy, M.,Kumar, H.V. and Reddy, P.R., 1972, Ind. J.Ophthal., 20, 101. |
15. | Wood, T.O. and Williford, W., 1976, Amer. J.Ophthal., 81, 847. |
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