Grand Round Infective Keratitis associated with Contact Lens Wear

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Grand RoundInfective Keratitis associated with
Contact Lens Wear
Jimmy Lim
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History

• Referred on 17th March 2005
• OS pain and redness for 4/7.
• Increasing photophobia.
• VA OD 6/6 OS 6/36-gt 6/92.
• Myope OU 7.50D.

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Contact Lens Hx

• Contact Lens user 5 years.
• 1/12 ago switched to monthly disposable soft
  contact lens.
• History of delayed disposal of contact lens.
• Wear 16 hours daily.
• Uses multipurpose cleansing solution.
• Did not take naps, sleep or swim with contact
  lens on.
• No prior topical steroid eye drops use
• No prior trauma.
• Only washes face with tap water with contact lens
  on.

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Clinical examination

• 1.5mm x 1.4mm cornea ulcer para-visual axis.
• Ring and feathery infiltrates .
• 30 cornea thickness.
• AC activity cells .
• No hypopyon.
• Cornea edema.

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Initial Inx and Rx

• Cornea scraping
• Chocolate, Blood and Sabourauds Agar.
• Gram stain.
• Admitted.
• G. Amphotericin 0.15 hourly.
• G.Gentamicin Cefazolin (Fortified) 3 hourly.

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Day 5

• Symptomatically improved.
• All anibiotics was kept.
• Amphotericin decreased 2 hourly.
• Clinically .
• Edema localised.
• AC 2 cells.
• Epithelial defect 1.1mm x 0.8 mm.
• Culture no growth so far.

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Review

• Day 7
• BCVA OS 6/9.
• Symptomatically improved.
• AC quiet .
• Amphotericin decreased 3 hourly.
• Day 11
• BCVA OS 6/60.
• Increasing photophobia.
• AC cells 3.
• Endothelial plaque seen.
• Epithelial defect.
• Rescraping done E.Coli non nutrient agar.
• Amphotericin increased 1 hourly.

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Review

• Day 12
• Readmitted for hourly Amphotericin and
  Moxifloxacin eye drop.
• Day 13
• BCVA OS CF closely.
• Worsening pain and photophobia.
• Lesion 3 x 3.2mm.
• Culture still negative.
• Added
• G.Chlorhexidine and Hexamidine hourly.

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Review

• Day 14
• Lesion inferiorly necrotic.
• Eye drops stopped .
• Listed for cornea biopsy 24 later.

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Cornea Biopsy

• Day 15
• Inadvertent full thickness wound during
  trephination.
• As lesion necrotic and purulent.
• Patch graft performed.

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Review

• Day 16 (Post biopsy Day 1)
• BCVA 6/120.
• AC cell .
• Hypopyon resolved.
• Wound water tight patch clear.
• Microbiologist
• Adequate sample, no filaments or fungi elements
  seen.
• Stopped cefazolin, gentamicin and
  anti-acanthomoeba medications.
• Added Pred Forte 1 tds, and increased to qds on
  Day 17.

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Review

• Day 19
• AC cells .
• Keratitic Precipitates .
• Graft slight edema.
• Amphotericin B and moxifloxacin. decreased to 3
  hourly and Pred forte 5x/day.
• Histopathology dense fibrosis no inflammation,
  culture no growth.

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Review

• Day 25
• Large central epithelial defect.
• Hypopyon 1mm.
• AC cells 2.
• Cloudy cornea.
• Loose sutures.
• Graft resutured
• Scrapes sent Viral culture and HSV 1 2 PCR.
• Culture for bacteria, fungus and histology.
• Started occ Acyclovir 5x/ day and oral Acyclovir
  800mg 5x/day.

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Review

• Day 26
• Infiltrate increased to 4.5mm .
• Hypopyon 1mm.
• Acyclovir was stopped and Added G. Natamycin
  hourly and oral Fluconazole 200mg bd.

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Review

• Day 28 (14th April 2005)
• BCVA PL.
• Large central abscess.
• Hypopyon 2mm.
• Culture no growth.
• Rescraped
• Inadvertent perforation.
• Emergency tectonic penertrating keratoplasty.

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Tectonic Penetrating Keratoplasty

• Day 30 (POD 1)
• BCVA 6/120.
• Cefazolin and gentamicin 3hourly.
• Natamycin qds.
• Pred forte 3 hourly.
• Fluconazole 200 mg bd.
• Hypopyon cleared, some fibrin AC cells 3.

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Post Graft

• Fungal culture Fusarium sp.
• Slow Epithelial defect healing.
• Left Tarsorraphy and Botox injection performed on
  POD 3, Tarso released POD 14 epithelial healed.
• Day 34 (POD 4)
• Pred forte -gt Dexamethasone PF 3hourly .
• Occ Ciloxan qds.
• Stopped fortified antibiotics and Pred Forte.
• Subsequently uneventful, STO for loose sutures
  performed.

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Last Review

• Post PK 9 months.
• Graft no sign of rejection.
• Ac quiet and deep.
• Dexa (preservative free) om.
• BCVA 6/7.5.

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Literature Review Fusarium Spp.

• Epidemiology (I. Doczi, editorial Clinical
  Microbiology and Infection, 2004)
• Hot, humid, tropical climates, (China, India ,
  Thailand, Singapore, Florida).
• Rare in temperate countries.
• Cornea trauma most common predisposing factor
  (incidence 31.6 to 89.9).
• Plant and animal matter.
• Topical corticosteroids, previous eye surgery,
  pre-exisitng ocular disease, contact lens wear.
• Systemic diseases eg. DM

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• Possible blinding complication.
• 10 out of 159 cases advanced Fusarium keratitis
  in Florida progressed to endophthalmitis. (Dursun
  D et al Cornea 2003)
• Proliferative and Migratory response (Dong X. et
  al Current Eye Research 2005)
• MMP-9 and MMP-2
• Most active in Day 3
• Degree of inflammation correlate with levels of
  MMP-9
• Hypae lay parallel to stromal lamellae.
• Cytotoxicity (Nalker S.et al Mycoses 2004)
• Mycotoxin-producing.

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Diagnosis

• Stains.
• 10 KOH wet mount.
• Sabourauds agar.
• Histology.
• PCR based tests(Gaudio PA et al BJO 2002).
• Confocal microscopy?

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Therapy

• Most effective (Kalavathy C M et al Cornea 2005)
• Primary Natamycin therapy for filamentous fungal
  keratitis.
• Tetraene polyene antibiotic derived from
  Streptomyces natalensis.
• Dose-related, natamycin is predominantly
  fungicidal.
• Polyenesterol complex alters the permeability of
  the membrane to produce depletion of essential
  cellular constituents.

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• Use of Suconjunctival Fluconazole (Yilmaz S et al
  AJO 2005)
• Penetrating Keratoplasty.

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