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| EDITORIAL |
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| Year : 1967 | Volume
: 15
| Issue : 1 | Page : 29-31 |
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Mycotic infections
SN Cooper
India
| Date of Web Publication | 18-Jan-2008 |
Correspondence Address:
S N Cooper
India
 Source of Support: None, Conflict of Interest: None  | Check |
How to cite this article:
Cooper S N. Mycotic infections. Indian J Ophthalmol 1967;15:29-31 |
Undoubtedly, of recent years, mycotic infections have come to the fore in all branches of surgery, particularly in ophthalmology.
It has been shown often enough, clinically and experimentally that injudicious use of antibiotics and cortico-steroids in the local treatment of the eyes has produced an increasing number of mycotic ocular conditions, although we can say with equal confidence that in a majority of cases of ocular mycosis that we have come across, there was no such history. Although this may allow us to neutralise that fear of getting a mycotic infection every time we use antibiotics and corticosteroids,-a fear created by such reports and experiments, our enthusiasm for the use of such drugs too freely and too frequently must be tempered with season. It would be preferable to use a soluble preparation of these compounds as drops, than to pile up the medication in the form of an ointment, the base of which is never guaranteed sterile and absorption from which is slow.
It is necessary to simplify the concepts of mycotic ocular infection. We come across it in two forms : (1) a corneal ulcer probably from an extraneous source and (2) a mycotic endophthalmitis of a metastatic or toxy-allergic nature from an intrinsic source. Fortunately, both these manifestations have typical clinical characteristics, which have been clearly brought out in the papers presented in this issue. Usually, we learn to diagnose these conditions only at the personal cost of our reputation and losing an eye or two in the beginning because of failure to distinguish the finer points in diagnosis in the hurry and scurry of attending to a large outdoor department. These ocular conditions are so rare that they are not easily thought of, not in one's early clinical experience at least.
Nevertheless, the clinical manifestations are so characteristic that they have Great diagnostic values. It is fortunate that it is so because to clinch the diagnosis by a cultural examination will take at least 10 days on Sabouraud's medium and other media for growing the fungi. By that time the condition may have progressed disastrously. Besides, a cultural examination shows no growth of fungi occasionally although some hyphen may be seen on a wet preparation taken from material directly from the source.
This point can be brought out by briefly narrating an instance under each of the two varieties, which we have come across in our clinical practice.
A boy, 12 years of age, was brought to us with a corneal ulcer following a foreign body in that eye a few days previously, which had been removed and treated elsewhere. The boy was from a middle-class family with no suggestion of malnutrition in him. The ulcer kept on progressing in spite of routine treatment and a yellowish-white dough was forming. A scraping from the floor and sides of the ulcer was put on Sabouraud's medium and the patient was called in the evening for an excision of the ulcer by lamellar keratectomy as is our practice in such cases. The parents of the patient wanted a definite prognosis, whether the ulcer would heal and the vision could be restored. As no guarantee could be given by us as regards arrest of the ulcer in view of the progressing nature of the ulcer and as the certainty of restoring vision without a late keratoplasty was definitely denied, the patient was never brought back. The culture proved. positive to candida albicans after 10 days. Thus a suspicion of mycotic keratitis on clinical grounds was confirmed 10 days later.
A man of 58 had his cataract removed by us last year. He had pus in the urine for which he had been regularly treated for years without any change. Ignoring this chronic cystitis which had been treated and was being treated with all the known forms of treatment, we did not hesitate to undertake the operation. But for the fact, that the capsule broke easily, on attempting an extraction of the lens intracapsularly, the operation was uneventful.
The chamber had formed nicely, but by about the fifth day, the chamber appeared shallow and there was some striate keratitis. He was discharged on the 7th day, as is our practice. On the 12th day, when he came for getting the stitches removed, the chamber was quite empty. The stitches were removed with the hope that the chamber would form on removing them. He gradually developed a granulomatous type of iridocylitis, the chamber remaining absent and a ground-glass like opacity of the cornea, was developing. The chamber had not formed even a week after removal of the stitches, inspite of all the known treatment for restoring an anterior chamber.
Under sodium-penthotal, the iris was separated from the cornea by an iris repositor, air was introduced into the anterior chamber and the wound was stitched again. The chamber again became empty and would not form.
A month later, a full iridectomy was done with separation of the iris and cornea again, and application of the stitches to the wound. The patient was being kept on anti-biotics and corticosteroids, locally, as well as parenterally. This time the chamber formed but the entire cornea gradually became ground-glass like. Comparatively, there was little vascular reaction. The vision was reduced to hand movements. Even then it did not occur to us that it could be endophthalmitis of mycotic origin.
A year later, the patient desired an extraction of the cataract of the other eye. This was done intracapsularly, under local anaesthesia, without any difficulty. The pus in the urine continued to be present inspite of all the urinary disinfectants used. From the third day, there appeared to be a mild keratitis with greying of the pupil. The chamber that had formed on the first three days, again showed signs of shallowing. It appeared that the history of the opposite eye was going to repeat itself in this eye. On slit lamp examination, when fibrinous looking exudate was seen in the anterior chamber, a diagnosis of mycotic endophalmitis was provisionally made. A metastatic infection of a toxic-allergic condition with a focus in the kidney, bladder or prostrate was assumed. The urine was taken and cultured on Sabouraud's medium. He was at once put on injections of iodine, until such time as the report on culture would be available.
The ocular condition seemed to be controlled and the progress appeared to have stopped. On the 10th day, a report on the culture was available which showed the growth of candida ablicans. He was at once put on micostatine tablets, one, three times a day, and the ocular condition began to show rapid improvement, with formation of anterior chamber, reduction of posterior and anterior synechia and clearing of the cornea. The pus cell count in the urine also, began to drop, though it never came down to nil.
This is a unique case where a distant focus of infection, probably of a mycotic nature, gave rise to either a metastatic endophthalmitis or a keratouveitis of an anaphylactic nature. The rapid improvement that has taken place, suggests the latter pathology.
It is fortunate that we have been able to collect a few papers on mycotic infections of the eve, which enabled us to bring out a separate issue on this subject, to make our readers "fungus-conscious", when a corneal ulcer progresses in spite of routine treatment and shows signs of iritis, hypophyon and slough formation in the ulcer. Post operatively a persistent shallow or absent anterior chamber after having formed once, should be an early indication of a threatening metastatic fungal endophthalmitis. In spite of the fact that the pendulum has swung to the other side in our concept of infections of the eye from a distant focus of infection (some maintain that this never occurs), the case quoted above should be an answer to that extreme concept. Such "focal" infections do occur and the examination of the genito-urinary tract in particular and a cultural examination of the urine on media for growing fungi, (forms of examination which are often omitted) should be instituted at an early date.
As regards treatment, it does not appear to be so hopeless as it is made out to be. An early diagnosis is of course a prerequisite, because a "lost" eye-ball cannot be retrieved. As regards mycotic corneal ulcers with or without a hypopyon, our practice is to excise the ulcer by lamellar keratectomy. There should be no hesitation in taking such a bold step, for one cannot wait for a report on the cultural examination. It is a form of debridement used in surgical practice for removing tissues which are necrosing and so provide a healthy base for repair. Keratoplasty at a later stage may have to be considered for optical purposes.
As regards antifungal agents, the two available in Bombay are "Grasovin" by Glaxo laboratories and "Mycostatin" by Squibb. They act on a variety of hyphce and fungi but there are some fungi which are resistant to all fungal remedies. In any case the action of anti-fungal drugs is slow and the treatment may be prolonged over a couple of months or more.
Iodine intravenously or even orally is useful as a nonspecific measure. Copper sulphate, copper propionate and 0.3% amphloterecin B as topical applications recommended by Putanna in his paper, we confess we have not tried out and cannot opine on the same. When we search for local applications of fungicidal agents for the eyes we find that there is none available in the market nor is one known as far as one could ascertain. There are a number of them available for the skin e.g. Betnoeate with chinoform. It is unfortunate that no pharmaceutical firm has interested itself in fungo-static or fungicidal topical agents for the different fungi that afflict the eye. Nor does any research seem to be in progress in this direction. The one angle that appeals to us is a search for a non-pathogenic bacterium that may inhibit the growth of such fungi. Since bacteriostatic agents promote fungal infections of the eye in some instances one wonders whether this clinical fact can be converted to fight the fungus by purposely introducing a nonpathogenic coccus, bacillus or a virus into the conjunctiva.
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