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   Table of Contents      
Year : 2002  |  Volume : 50  |  Issue : 3  |  Page : 213-214

Simultaneous bilateral fungal keratitis caused by different fungi.

Aravind Eye Hospitals, Postgraduate Institute of Ophthalmology, 1 Anna Nagar, Madurai-625 020, India

Correspondence Address:
N Venkatesh Prajna
Aravind Eye Hospitals, Postgraduate Institute of Ophthalmology, 1 Anna Nagar, Madurai-625 020
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Source of Support: None, Conflict of Interest: None

PMID: 12355697

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Fungal keratitis is an important cause of corneal disease in the tropical world. We report a rare presentation of simultaneous bilateral corneal ulceration caused by different fungi.

Keywords: Fungal keratitis, bilateral corneal ulceration

How to cite this article:
Prajna N V, Rao RA, Mathen MM, Prajna L, George C, Srinivasan M. Simultaneous bilateral fungal keratitis caused by different fungi. Indian J Ophthalmol 2002;50:213-4

How to cite this URL:
Prajna N V, Rao RA, Mathen MM, Prajna L, George C, Srinivasan M. Simultaneous bilateral fungal keratitis caused by different fungi. Indian J Ophthalmol [serial online] 2002 [cited 2019 May 20];50:213-4. Available from:

Keratomycosis is common in tropical countries like India especially in dry, windy weather following a wet period. More than 70 genera of fungi and yeasts have been associated with keratomycosis.[1] In India the common fungi isolated are Fusarium species, Aspergillus species and rarely, pigmented fungi.[2] Reports on bilateral fungal keratitis are rare and there has been no report on simultaneous bilateral fungal keratitis caused by different fungi. We report a case of a diabetic lady with lamellar ichthyoses who had simultaneous bilateral fungal keratitis caused by two different (one pigmented and the other non-pigmented) fungi.

  Case report Top

A 60-year-old female presented to us with complaints of redness, pain and defective vision in both eyes of two weeks' duration. There was no history of preceding trauma. She gave a history of a dermatological disease present since early childhood, diagnosed as lamellar ichthyoses, but never treated. She was a diabetic for the past five years on irregular treatment.

General examination showed a well-built individual with normal cardiovascular, respiratory and central nervous systems. The skin over her entire body was dry, pigmented, scaly and tightly stretched, particularly over the elbow and knee joints.

On ocular examination, the visual acuity was hand movements close to face in both eyes. Bilateral cicatricial ectropion involving the lower lids and lateral aspects of the upper eyelids was present [Figure:1]. Both eyes had mild cicatricial lagophthalmos. The conjunctiva of both the eyes was diffusely congested and chemosed. Slitlamp examination of the right cornea showed a large (7 X 8 mm), central white coloured corneal ulcer involving almost the full thickness of the cornea. The surface was dry and slightly elevated, and the margins were well circumscribed. An accompanying 1-mm hypopyon was also present [Figure:2a]. Slitlamp examination of the left cornea showed a 7 X 7 mm, brownish black, central corneal ulcer, involving almost the full thickness. The elevated surface of the ulcer had black pigments and the margins had characteristic feathery edges with an accompanying 2-mm hypopyon [Figure:2b].

Both ulcers were scraped under local anesthesia, using a Kimura's spatula. Smears were obtained for 10% potassium hydroxide and Gram's stain. The culture was taken on blood agar (BA), chocolate agar (CA), brain heart infusion broth (BHI) and potato dextrose agar (PDA). Smears from both eyes revealed fungal filaments. All the plates were incubated at 37C except PDA, which was kept at room temperature. The PDA plates from both the eyes showed a contrasting colour and growth pattern [Figure:3]. After 24 hours, the culture from the right eye grew greenish yellow, powdery colonies. A lactophenol cotton blue (LPCB) mount of the colony showed conidiophores arising directly from the hyphae ending in a bulbous vesicle with the phialides arising from the vesicle, characteristic of Aspergillus flavus [Figure:4a]. The culture from the left eye after 48 hours had woolly, greyish black colonies and a LPCB mount showed pale brown conidia with three transverse septae with central cells larger and darker, consistent with Curvularia lunata [Figure:4b]. The patient was treated with topical natamycin 5 % suspension applied hourly in both eyes for five days and then two hourly. Both ulcers showed signs of healing after 10 days.

  Discussion Top

Fungal keratitis is an important cause of corneal disease and is reported to constitute up to one-third of all cases of suppurative keratitis in tropical parts of the world.[3] The simultaneous occurrence of bilateral fungal keratitis, caused by different fungi has not been reported so far to the best of our knowledge. Bilateral bacterial keratitis after laser in-situ keratomileusis has been reported in immunocompetent[4] and immuno-compromised[5] patients. Our patient had lamellar ichthyoses, which is a heterogeneous group of inherited skin disorders. It is known to cause lagophthalmos and ectropion of the lids, which can predispose to corneal scarring and infection.[6] The presence of ectropion of the lids, lagophthalmos, possible pre-existing corneal scarring and uncontrolled diabetes mellitus were the predisposing factors for the development of bilateral fungal keratitis in this case. However, the interesting feature was that one eye was affected by Aspergillus and the fellow eye was affected by Curvularia. Although Aspergillus and Curvularia have been reported as causes of fungal keratitis, the simultaneous occurrence in the same patient is a curiosity.

  References Top

Forster RK. Fungal diseases. In: Smolin G, Thoft RA, editors. The Cornea: Scientific Foundations and Clinical Practice. Boston / Toronto: Little, Brown and Company; 1987. pp 228-40.  Back to cited text no. 1
Srinivasan M, Gonzales AC, George C, Cevallos V, Mascarenhas MJ, Asokan B, et al. Epidemiology and aetiological diagnosis of corneal ulceration in Madurai, South India. Br J Ophthalmol 1997;81:965-71.  Back to cited text no. 2
Thomas PA, Kalavathy CM, Rajasekaran J. Microbial keratitis: A study of 774 cases and review of the literature. J Madras St Ophthal Assoc 1986;23:13-21.  Back to cited text no. 3
Watanabe H, Sato S, Maeda N, Inoue Y, Shimomura Y, Tano Y. Bilateral corneal infection as a complication of laser in situ keratomileusis. Arch Ophthalmol 1997;115:1593-94.  Back to cited text no. 4
Hovanesian JA, Faktonovich EG, Hoffbauer JD, Shah SS, Maloney RK. Bilateral bacterial keratitis after laser in situ keratomileusis in a patient with human immunodeficiency virus infection. Arch Ophthalmol 1999;117:968-70.  Back to cited text no. 5
Antonio AV, Cruz AAV, Menezes FAH, Chaves R, Coelho PR, Velasco FE, Kikuta H. Eyelid abnormalities in lamellar ichthyoses. Ophthalmology 2000;107:1895-98.  Back to cited text no. 6

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