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N. Acharya, B. Paton, K. Colby; Spectrum of Fungal Keratitis at Massachusetts Eye and Ear Infirmary . Invest. Ophthalmol. Vis. Sci. 2003;44(13):1410.
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Purpose: To review and compare the clinical experience with fungal keratitis at an urban northeastern academic eye hospital with results from other geographic areas. Methods: Twenty-three cases of fungal keratitis were identified in the microbiology laboratory of the Massachusetts Eye and Ear Infirmary between January 1999 and November 2002, and these medical records were reviewed. Results: Out of the 23 cases, 61% were male. The mean age was 56 years. Predisposing risk factors included chronic ocular surface disease (77%), topical steroid use (45%), penetrating keratoplasty (45%), contact lens wear (18%) and ocular trauma (13%). Thirty-nine percent of initial Gram and/or Giemsa stains demonstrated fungal elements. An initial positive fungal culture was obtained within 3 days for 42% of patients and within 7 days for 79% of patients. Seventy percent of cases had infection caused by yeast, and the other 30% were caused by filamentous fungi. Candida species (C. parapsilosis and C. albicans) were the most commonly isolated organisms, followed by Fusarium and then Aspergillus. Forty-four percent of patients began treatment with Amphotericin drops alone, while 22% were initially treated with Natamycin and Amphotericin drops. Forty-eight percent had systemic antifungal treatment. Topical steroids were used in 22% of patients but not started until a mean of 41 days after diagnosis. Thirty-five percent of patients had penetrating keratoplasty during the acute stages of infection: one-half for corneal perforation and one-half for progression of infection despite medical treatment. After a mean follow up of 7.3 months, 65% of patients had counting fingers vision or less, and 22 % had vision better than or equal to 20/100. Conclusions: In our series from the northeast, Candida species was the most common isolate in cases of fungal keratitis. This is in contrast to the southern United States, where filamentous fungi predominate. Candida infection is typically associated with immunosuppression, and we indeed found that chronic ocular surface disease, topical steroids and history of penetrating keratoplasty were the greatest risk factors. Sensitivity of initial cultures was considerably higher than that of gram or Giemsa stains alone. Despite aggressive medical and surgical treatment, the majority of patients had counting fingers vision or less at follow-up. Given these results, in the northeastern United States one should consider the possibility of fungal infection due to yeast in patients with infectious keratitis, particularly in individuals with chronic ocular surface disease and local immunosuppression.
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