Ayyaz Hussain Awan, Javaid Usman.
Superficial Keratectomy in Fungal Keratitis.
Pak J Ophthalmol Jan ;15(3):124-6.

A case of fungal keratitis is presented which did not respond to local and systemic antifungal treatment alone, so surgical option had to be resorted to. Superficial keratectomy was performed which had a remarkable effect on the ocular affection.

CASE REPORT: A 26-year-old male presented to the department of ophthalmology at the Combined Military Hospital, Bahawalpur, with 2 weeks history of trauma to the right eye (RE) from vegetable matter. On examination: Vision RE (VR)-6/18 (with P.H.-6/9). Slit-lamp (S/L) microscopy revealed a lxlmm superficial, round, whitish corneal ulcer with adjacent stromal infiltration. Anterior chamber (AC) had cells ++. No flare was seen. After taking corneal and conjunctival swabs for bacterial and fungal cultures, the patient was put on local 0.3% genticyn, 1% mydriacyl, nizoral eye drops and mycospor (Bifonazole) cream. His ocular condition improved. His cultures were negative and he was discharged symptom free after 15 days. He returned 4 weeks later with complaints of pain and watering from the right eye of 2 days duration. VR-6/36. On S/L examination a well- defined grayish white, oval corneal ulcer with associated stromal abscess and adjacent stromal infiltration was seen. AC had cells +++. As there was history of vegetable matter injury, suspecting it to be a fungal corneal infection, he was placed on oral nizoral 2 tabs once daily, local nizoral eye drops 2 hourly, mycospor cream 5 times a day and 1% mydriacyl eye drops 8 hourly. Tab co-trimoxazole 960 mg 12 hourly and neosporin eye drops 4 hourly were started to prevent superimposed bacterial infection. Gram stain of the abscess was negative for bacteria. The purulent material was cultured on two plates of blood agar (one incubated aerobically and the other anaerobically), one plate of chocolate agar and one plate of MacConkey`s agar. All these plates were incubated at 37°C. After 48 hours no growth was seen on the blood, chocolate and MacConkey`s agar. Reexamination after 2 days showed no improvement; rather the patient started complaining of severe pain in the RE even with full mydriasis. So inj. genticyn 80mg I/V 8 hourly and Inj. dicloran I/M 8 hourly were started. Three days later the stromal abscess increased in size and depth and finger-like projections appeared in the adjacent stroma with endothelial plaque formation and iris adhesion. Thus injection genticyn and tab co-trimoxazole 960 mg were withdrawn and inj ceftriaxone 2 gm I/V once daily and diclofenac sodium eye drops 4 hourly were started. After 5 days of treatment still there was no improvement, so a superficial keratectomy with diagnostic and therapeutic aims in mind was planned. Using a No. 15 blade a superficial keratectomy was done and a superficial corneal flap was raised. About 40-50% of the stromal abscess was drained and sent for bacterial and fungal examination. Mycospor cream was instilled and the eye was padded. Complaints of pain right eye reduced dramatically, so inj dicloran was withdrawn. The superficial corneal wound healed uneventfully and after 2 days a green shade was given. Ocular condition improved gradually. The Sabouraud dextrose agar revealed growth of a fungus, initially white, later becoming green with powdery surface after eight days of incubation at 30°C which on microscopy in lactophenol cotton blue preparation yielded septate hyphae, branching conidiophores and chains of conidia belonging to the Penicillium species. So inj. ceftriaxone was omitted. Due to the gradual improvement in ocular condition all the medications were tapered over the following 20 days. He was discharged symptom free and advised to come back for follow-up after 2 weeks. On follow-up he had no complaints and had resumed his duties. On examination: VR was 6/9. On S/L examination a leucomatous corneal opacity was seen at the site of trauma. The eye was quiet.

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