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I See Trees of Green
Red Roses Too
I See Them Bloom For Me & For You
And I Think To Myself , Such A Wonderful World
I See Skies Of Blue

And Clouds Of White
The Bright Sunny Days
The Dark Sacred Nights
And I Think To Myself

What A Wonderful World
Prevent trauma

Tears :
Lysozyme,
Lactoferrin,
ceruloplasmin,B
lysin, Complement
& Ig`s
Conjunctival
follicles &
leukocyte
defense
ANATOMY
ANATOMY

Rich vascular
supply
FUNGAL INFECTIONS OF THE EYE
Presenter: Dr. Vinaykumar Hallur
Moderator: Dr. M.R. Shivaprakash


Periocular Fungal Infections



Mycoses of the Anterior Segment of the Eye



Fungal Endophthalmitis



Laboratory diagnosis



Management



Experimental models
KERATOMYCOSIS






First described by Leber (Aspergillus species) in 1879
Major cause of blindness in Asia
Incidence low in Britain & North USA
6-53% of all cases of ulcerative keratitis in Asia
Can occur alone or coexist with a bacterial
infection(14.1%)
[Basak et al Indian J Ophthalmol. 2005 Jun;53(2):143]



Earlier phaeoid fungi (Dematiaceous) not considered to
be significant but now are important cause of
keratomycosis .
Rare
EPIDEMIOLOGY
PREVALENCE
North India
South India
Eastern India
Western India

North India : Aspergillus40% ,Fusarium
16%, Curvularia 8%, 1994- Chander et al.,
Aspergillus 35 %, Fusarium 23%, Acremonium
12%, 1993-Chander et al.

82.3%
46.1%
32.0%
38.9%
South India : 34.4% fungal keratitis,
Fusarium 2007 Bharathi et al, Fusarium
43%, Aspergillus 26%, 30.00% Fungi
keratitis in India isDematitiousof
25% 2003 – Bharathi et al

Total prevalence of fungal
total cases
Total prevalence of fungal keratitis in western 8.00%
countries
IJO Sep 2001


AGE

21 -50 YEARS



SEX

M>F



RESIDENCE



SOCIOECONOMIC STATUS



OCCUPATION

 SEASONS

(3:1)

RURAL >URBAN
LOW > HIGH
FARMERS, LABOURER.

AUTUMN, RAINY.

Cornea 2000; August:555-59
PREDISPOSING FACTORS
• Trauma
vegetable matter
metallic foreign body
sand/stone
• Chronic topical medication
• Diabetes Mellitus
• Topical or systemic corticosteroids
• Extended wear/bandage contact lens
• Penetrating keratoplasty
• Anterior uveitis
• Herpes simplex keratitis
ETIOPATHOGENESIS
Over 70 genera can cause mycotic keratitis
 Fungi of importance in microbial keratitis
 Moniliaceae
-- Aspergillus (90%) Most common cause in World
-- Fusarium(1%)Second most common cause
--Paecilomyces.
--Penicillium.
--Pseudallescheria.


Data in brackets from Dept of ophtahlmology, PGIMER
CONTD..
• Dematiaceae.
--Curvalaria. (2%)
--Alternaria.
--Phialophora.
--Bipolaris.
--Exserohilum.
--Cladosporium.
-- Colletotrichum
• Yeast.
--Candida. (2.5%)
--Cryptococcus

• Dimorphic fungi.
--Blastomyces.
--Coccidioides.
--Histoplasma.
--Sporothrix.
Fungal infections of the eye
• PATHOGENESIS
-Breach in epithelium
-Compromised cornea
-Immunocompromised

Contact of fungal hyphae with cornea

Filamentous

Yeast
FUNGAL ADHERENCE


Filamentous Fibrinogen receptors on mature
conidia of aspergillus and fusarium



Yeast Integrin analogue, Fibronectin
receptor, Adhesive mannoprotn, Aspartyl
proteinase, Factor 6 , Endo. adhesions.
PENETRATION


Filamentous fungi: Parallel growth of hyphae to stroma, f/b
release of mycotoxins, proteolytic enzymes, soluble fungal
antigen



Yeast: Proliferate parallel & perpendicular to corneal stroma
f/b release of protease and lipase
HOST RESPONSE FILAMENTOUS
inablity of PMN,leucocyte cell for phagocytosis
destruction of corneal stroma
penetrate descement membrane

enterAC
accumulate around lens
seclusion of pupil
fungal glaucoma
HOST RESPONSE YEAST
inability of PMN cell to ingest pseudohyphae and hyphae
furstated phagocytosis by PMN

destruction of stroma

melting of cornea
CLINICAL FEATURES
•
•
•
•
•

Signs >> symptoms
Manifest within 24 – 48 hours
Patient present within 1st week
EARLY BI-MICROSCOPIC FINDING
Fine or coarse granular infiltrate within the epithelium
and anterior stroma
• Minimal stromal infiltrate
• Epithelial surface is dry rough textured, dirty gray in color
CONT………
• Epithelium may be intact or ulcerated.
• Pigmented and delicate ,feathery branching hyphae with
surrounding infiltrate
• Multifocal suppurative microabsscess or satellite lesion
CONTD….

• Advanced lesions
o Dense fibrinous material adhering to endothelium and iris
o Total stromal infiltrate and necrosis
CONTD…………..
•
•
•
•
•
•
•

Other signs
White ring (Wessely`s ring)
Conjunctival hyperemia
AC reaction
Hypopyon
endothelial plaque
Mild iritis
YEAST KERATITIS
• Risk Fatcors
• Previously compromised cornea
• SYSTEMIC DISEASE
Sjogren’s syndrome
Erythema multiforme
IgA deficiency
HIV
Endocrinopathy
CLINICAL FEATURE OF CANDIDA INFECTION

• Ulcer is small oval with expanding discrete sharply
demarcated ,dense yellow –white stromal suppuration
• Feathery margins are not seen
FUNGAL ENDOPHTHALMITIS


a suppurative inflammation of inner ocular coats
and their adjacent structure



with involvement of anterior chamber and
vitreous fluid,



caused by various fungal agents
FUNGAL ENDOPHTHALMITIS


Clinically two types


Endogenous due to hematogenous spread



Exogenous due to trauma or post operative
EPIDEMIOLOGY


The first description of endogenous fungal
endophthalmitis was by Dimmer in 1913



Candida endopthalmitis clinical entity in 1958



In U.S.A. compared to previous decades Endophthalmitis
Increase from last few decades.



Incidence is increasing because of modern medical
practices



USA 30 % candidemia(Last 3 decdes) develop
endopthalmitis, now there is a lower incidence because
of prophylacyic antifungals
CMR, October 2000, p. 662–685
PATHOGENESIS ENDOGENOUS


Multifactorial.



It is likely that sustained fungemia with even
saprophytic fungi can lead to endopthalmitis
Gupte et al -contaminant IV fluids,11 / 72 IV fluid samples culture
positive for fungi



At the time of initial infection with some
dimorphic, fungi, such as H. capsulatum & C.

immitis, unrecognized fungemia occurs and often
leads to endophthalmitis.
ENDOGENOUS
ENDOPHTHALMITIS
 Predisposing

factors



Systemic debilitating disease



Malignancy



IVDU



Chemotherapy



Systemic antibiotics



Alcoholism &



Diabetes
PATHOGENESIS ENDOGENOUS



More common in immunocompromised ie pts on
chemo or IV drug abuse



Marked trophism for eye because peculiar blood
supply of the eye.
PATHOGENESIS: EXOGENOUS


Occurs in immunocompetent people



Direct introduction of the organisms following


Surgery(Catarct removal with placement of IOL mainly

Candida spp)


Trauma(Mainly Fusarium spp. )



I/O spread from Fungal keratitis
EPIDEMIOLOGY



RACE – no racial preponderance



SEX – Male preponderance (3:1)



AGE – Young and middle age.
MORBIDITY
 Prognosis





depends upon

virulence of organism
extent of involvement
timing
mode of intervention

 Prompt

therapy following early diagnosis helps to
reduce visual loss

 Visual

outcome of aspergillus endo. is poor d/t
macular involvement.
AGENTS
Endogenous Endotphthalmitis


Candia albicans



Fusarium species



Aspergillus species



Histoplasma capsulatum



Coccidioides immitis



Blastomyces dermatitidis



Cryptococcus neoformnas
C. ALBICANS


M.C.C of endogenous endopthalmitis



Infection usually starts from Choroid and then spreads to
retina



Non candida albicans fungemia & endopthalmitis is increasing
and is concern because of antimicrobial resistance
CANDIDIAL ENDOPTHALMITIS

Current Eye Research, 1–11, Early Online, 2010
ASPERGILLUS ENDOPTHALMITIS


A. flavus second MCC



Spreads from lungs to eye



This is f/b A. fumigatus, A. niger, A. terreus, A.
glaucus , & A. nidulans .
CRYPTOCOCCAL ENDOPH.


Cryptococci spores survive in pigeons dropping



From lung, fungus – disseminated
haematogenesouly and can affect CNS causing
fungal meningitis & endophthalmitis in eye



Choroids is the probably first site of ocular
infections
AGENTS

Exogenous
Endophthalmitis
Aspergillus spp.
 C. albicans,C. glabrata, C. tropicalis, C. parapsilosis
 Paecilomyces spp.
 Fusarium spp.
 Acremonium spp.
 Curvularia spp.

PRESUMED OCULAR
HISTOPLASMOSIS


Occurs in immunocompetent individuals



Recognized by presence of multiple atrophic chorioretinal
scars w/o vitreous or aqueous humor inflmn.



Affect 2,000 new individuals a year in areas of endemicity and
in some cases may lead to visual loss and blindness



Arises from hematogenous spread



Not detectable in the scars of POH



Strong epidemiological evidence, principally deriving from skin
test surveys, linking the scars to histoplasmosis
CLINICAL FEATURES
Symptoms
Visual loss
 Pt. may be asymptomatic if the lesion is in the
peripheral retina
 Red eye.
 Photophobia.
 Pain.
 Floaters.
 Scotoma



Many have a classical appearance with
progressive granulomatous uveitis
 diffuse retinitis
 deep vitreous abscess.




Time to make diag. from onset of symptoms, 3 d to
4 months.
DEPARTMENTAL DATA
Fungal infections of the eye
PERIOCULAR INFECTIONS
Agent
 Palpebral
Aspergillosis
Blastomycosis

involvement

No of cases in literature
2
12

As a part of generalized or local disease
3
C. albicans
 First reported case  1922 case of sporotrichosis
6
Coccidioidomycosis


3
Cryptococcus spp.
 Tinea faciale
11
Dermatophyte
 Aspergilloma, sporotrichosis  Chalazion
5
Paracoccidioidomycosis

7
Rhinosporidiosis
 Blastomycosis, Coccidioidomycosis  Basal cell carcinoma
5
Sporothrix spp.
INFECTIONS OF THE LACRIMAL GLAND


Fungi found to account for only 5% of infections .



14% of cases of congenital dacryocystitis



Principally Aspergillus spp. and C. albicans implicated



Epiphora is only clinical finding



Lid edema, conjunctival injection, and swelling in the
medial canthus; pressure over the area usually results in

a purulent discharge through the lower punctum
Thomas, CMR, Oct 2003,
FUNGAL INFECTIONS OF ORBIT
Proximity of sinuses to orbit, susceptible host & pathogen
 Zygomycosis


Rhinoorbitocerebral : one-third to one-half of all cases,
Incidence increasing
 Major risk factor : uncontrolled diabetes mellitus(70% DKA)
 Other predisposing factors










Chronic alcoholism
Renal transplantation
Hematological malignancies
Steroid therapy
Breach of skin

Starts with symptoms consistent with sinusitis Bloody nasal
discharge  Diplopia and loss of vision

Chakrabarti et al., 2006
INFECTIONS OF ORBIT


Invasive aspergillosis
 Increased frequency infection :widespread prophylaxis with
fluconazole
[VanBurikJH et al. The effect of prophylactic fluconazole on the clinical Spectrum of fungal diseases
in bone marrow transplant recipients with special attention to hepatic
candidiasis.Medicine(Baltimore) 1998;77:246−54.]



Exact prevalence of invasive aspergillosis in India is not known
[Chakrabarti et al , Japanese Journal of Medical Microbiology vol 49, 165-72, 2008]
INVASIVE ASPERGILLOSIS


Other fungi mimicking aspergillosis
Bipolaris spp.
 Alternaria spp.
 Curvularia spp.
 C. immitis
 B. dermatitidis
 Histoplasma spp.
 Penicillium spp.




C/F
orbital inflammation & a red proptotic eye with or without
associated pain
 ophthalmoplegia may develop
 Embolization of vessels of the optic nerve, or direct
involvement of the nerve may occur

FUNGAL CONJUNCTIVITIS





Can occur indepently or with keratomycosis
Clinically rare entity
Fungi may be present without causing inflammation in~
25% pts
Topical application tetracycline X 4 wks increased
prevalence 28.7%
[Nema, H.V., O.P. Ahuja, A. Bal and L.N. Mohapatra, Effects of topical corticosteroids
and antibiotics on mycotic flora of conjunctiva. Am. J. Ophthal., 1968. 65: p. 747–750].



Topical applications of corticosteroids X 3 wks increase
prevalence of fungi 18.8-67%
[Mitsui, Y. and J. Hanabusa, Corneal infections after cortisone therapy.
Br. J.Ophthal., 1955. 39: p. 244–250.]




C. albicans follows steroid LA  Pseudomembrane
Other organisms Aspergillus, Blastomycosis, Sporothrix,
Coccidiodomycosis
EXPERIMENTAL MODELS FK


Albino, wild rabbit , Dutch belted rabbit



Previously immunocompromised



Fractionated cobalt whole-body radiation



administration of antilymphocyte serum





corticosteroids locally or systemically

alloxan-induced diabetes

Intra lamellar injection or Superficial inoculation of
spore suspension
CONTD..


IL inoculation :


C. albicans, C. krusei, C. tropicalis, C. pseudotropicalis,
Aspergillus spp., Cephalosporium spp., F. solani, Lasiodiplodia sp.



Superficial inoculation:


C. albicans, C. tropicalis, C. pseudotropicalis, Aspergillus spp.,

Allescheria boydii, Cephalosporium spp., Geotrichum sp.


Antibacterial prophylaxis & use of characterized strain
ensures reproducibilty.



IO penetration of ketokonazole in rabbit has been tried
as a therapeutic modaliities
OTHERS


Mice
BALB/c mice
 ip cyclophosphamide 180 mg/kg 1,3, & 5d
 Scarified corneas /keratoplasty rat cornea in b/w space
 topically inoculated
 Easy handling




Rat
Wistar rats or Lewis rats
 Suitable size & immune response
 Size of eyes better surgical manipulation




Pigs




Large size, ease of fitting contact lens

Owl monkeys


Not better than Rabbit keratomycosis model
ENDOPHTHALMITIS MODELS


Rabbits
Both immunocompetent and immunocompromised rabbits are used
 Used mainly for endogenous endophthalmitis
 0.5 ml of 2 X 107 org/ ml into auricular vein
 intravitreal inoculation of 1,000 CFU of susceptible C. albicans


Junko et al Jpn. J. infect. Dis., 60, 33-39, 2007



Mice
Fusarium solani in immunocompetent mice
 Inocula of 5 x 10(6) conidia
 injected into the lateral tail vein


Mayayo et al Med Mycol. 1998 Oct;36(5):249-53
Fungal infections of the eye
DIAGNOSIS


History



Physical examination



Detailed examination of the affected



High risk of suspicion
LABORATORY DIAGNOSIS


Sample collection and transport







Biopsy
Corneal scraping, corneal button
AC tap
Vitreous tap
Fluids
Lens



Swabs not encouraged



Sterile leak proof container ASAP



Delay 4°C with exception of blood and vitreous (30-37°C ) &
swab (15%)
SAMPLES


Detailed examination of affected eye using slit lamp



Tissues diagnostic material harvested by
experienced ophthalmologist after LA or SA
Biopsy
 Scraping :15 Bard – parker surgical blade from the base &
margin(thoroughly) of ulcer aseptically or Kimura’s platinum
spatula
 Impression smear(Jain et al 2006 – PGIMER, Chandigarh –
equally sensitive and specific as Scrappings)
 Vitreous tap 300 microL using 23 G needle
 Aqeous tap 200 microL using 23 G needle

CONVENTIONAL TECHNIQUES


Direct microscopy
Rapid and cost effective
 10% KOH preparation
 Gram & Geimsa stain
 Calcoflour Stain – Easy and fast
 H&E, GMS, PAS, cytologic preparation




Culture
SDA, Blood agar,
 CHROM agar




Susceptibility testing


According to CLSI guidelines
CONVENTIONAL


Nonspecific fluorescent stain – {calcoflour
white, blankophor, uvitex 2B} –


used in tissue sections and



cytopathologic preparation of rapid diagnosis of mycotic infections.



Chander et al. Sensitivity of Calcofluor white – 95.2% compared to
71.4 % for KOH and culture.



fluorescent microscope



wavelength of 365 nm.



Acridine orange staining – useful in early diagnosis of
keratomycosis



PAS (Periodic acid schiff) stain can also use.
CULTURE


Corneal scraping inoculated on agar plate as a ‘C’ or ‘S’
shaped streak incubated at 25 & 37°C X 4wks



Fungal growth in the form of the streak ensure that the
growth is from the inoculum / specimen rather than a
laboratory contaminant.



Two sets of SDA with antibiotic, inoculated and incubated
at 250 C & 370C separately x 4 wks.
Keeping a possibility of dimorphic fungi
CULTURE


Vitreous fluid inoculated on routine fungal culture
media .



Vitreous sample should be concentrate either by



centrifugation
Millipore filtration
CULTURE


All the culture checked
everyday during first week and
 twice a week during next 3 week weeks.




Positive culture are more convincing


when growth is obtained on more than one occasion.
CONVENTIONAL TECHNIQUES


Serological techniques



Diagnosis of Histoplasmosis, Blastomycosis
MOLECULAR TECHNIQUES


PCR based detection methods


PCR
Rapid molecular identification of fungal pathogens in corneal samples from suspected
keratomycosis cases. J Med Microbiol. 2006 Nov;55(Pt 11):1505-9.



PCR - SSCP
Sensitive and rapid polymerase chain reaction based diagnosis of mycotic keratitis
through single stranded conformation polymorphism. Am J Ophthalmol. 2005
Nov;140(5):851-857.



Nested PCR
Comparative study of Gram stain, potassium hydroxide smear, culture and nested PCR in the
diagnosis of fungal keratitis. Ophthalmic Res. 2010;44(4):251-6.
MOLECULAR TECHNIQUES


PCR-RFLP
Diagnosis of Aspergillus fumigatus endophthalmitis from formalin fixed paraffinembedded tissue by polymerase chain reaction-based restriction fragment
length polymorphism Indian J Ophthalmol. 2008 Jan-Feb;56(1):65-6.



Real time quantitative PCR
Detection and quantification of pathogenic bacteria and fungi using
real-time polymerase chain reaction by cycling probe in patients with

corneal ulcer. Arch Ophthalmol. 2010 May;128(5):535-40.
PRINCIPLES OF TREATMENT


As with any other fungal infection , look & treat for

any predisposing illness


Confirm lab diagnosis



Look for and treat any superadded infection



Remember


Poor penetration of antifungal drugs



Corticosteroids are contraindicated



Use both surgical and medical approach whenever needed



Close follow up is required
FUNGAL KERATITIS


Superficial (early keratitis):
Topical natamycin (5%) (hyphae)
 Topical 0.15% amphotericin B or topical fluconazole (yeasts)
 Debridment of the epithelium




Deeper and larger lesions:
Subconjunctival or intravenous miconazole
 Ketoconazole, itraconazole, fluconazole or voriconazole (p.o.)
 Intracameral amphotericin B




Surgical treatment:
Cyanoacrylate tissue adhesive
 Amniotic membrane transplantation
 Penetrating keratoplasty

ENDOGENOUS
ENDOPHTHALMITIS


Systemic antifungal agents: Fluconazole,
voriconazole (azole compounds)



Systemic antifungal agents: Amphotericin B:
Parenteral ± intravitreal



Pars plana vitrectomy
EXOGENOUS ENDOPHTHALMITIS




Intraocular (intracameral ± intravitreal) amphotericin B
Intravitreal voriconazole or miconazole
Subconjunctival antifungal agents: when associated with
keratitis



Systemic antifungal agents:
fluconazole, ketoconazole, voriconazole, itraconazole, m
iconazole, and amphotericin B: important in
immunocompromised patients



Pars plana vitrectomy
MUCORMYCOSIS



Radical surgery+ antifungal therapy + correcting
underlying conditions



Amphotericin B Ist DOC(Amphotericin B given IV at
a daily dose of 1.0-1.5 mg/kg infused during 2-4 hr
for a total of 1-4 g)



Lipid formulations of amphotericin B alternative
Ferri: Practical Guide to the Care of the Medical Patient, 8th ed
INVASIVE ASPERGILLOSIS


Voriconazole 6 mg/kg IV q12h for 2 doses, then

4 mg/kg q12h PO Rx for adults is 200 mg bid or
4 mg/kg bid.


Caspofungin in pts who fail to respond to or are
unable to tolerate other antifungal drugs. The
recommended dosage is 70 mg on the first day and
50 mg qd thereafter given as a single dose IV over
1 hr.
Ferri: Practical Guide to the Care of the Medical Patient, 8th ed
Even though we cannot live forever, let our eyes live and give
sight for the needy! I have pledged my eyes, you can do that too..

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Fungal infections of the eye

  • 1. I See Trees of Green
  • 3. I See Them Bloom For Me & For You
  • 4. And I Think To Myself , Such A Wonderful World
  • 5. I See Skies Of Blue And Clouds Of White
  • 8. And I Think To Myself What A Wonderful World
  • 9. Prevent trauma Tears : Lysozyme, Lactoferrin, ceruloplasmin,B lysin, Complement & Ig`s Conjunctival follicles & leukocyte defense
  • 12. FUNGAL INFECTIONS OF THE EYE Presenter: Dr. Vinaykumar Hallur Moderator: Dr. M.R. Shivaprakash
  • 13.  Periocular Fungal Infections  Mycoses of the Anterior Segment of the Eye  Fungal Endophthalmitis  Laboratory diagnosis  Management  Experimental models
  • 14. KERATOMYCOSIS      First described by Leber (Aspergillus species) in 1879 Major cause of blindness in Asia Incidence low in Britain & North USA 6-53% of all cases of ulcerative keratitis in Asia Can occur alone or coexist with a bacterial infection(14.1%) [Basak et al Indian J Ophthalmol. 2005 Jun;53(2):143]  Earlier phaeoid fungi (Dematiaceous) not considered to be significant but now are important cause of keratomycosis .
  • 15. Rare
  • 16. EPIDEMIOLOGY PREVALENCE North India South India Eastern India Western India North India : Aspergillus40% ,Fusarium 16%, Curvularia 8%, 1994- Chander et al., Aspergillus 35 %, Fusarium 23%, Acremonium 12%, 1993-Chander et al. 82.3% 46.1% 32.0% 38.9% South India : 34.4% fungal keratitis, Fusarium 2007 Bharathi et al, Fusarium 43%, Aspergillus 26%, 30.00% Fungi keratitis in India isDematitiousof 25% 2003 – Bharathi et al Total prevalence of fungal total cases Total prevalence of fungal keratitis in western 8.00% countries IJO Sep 2001
  • 17.  AGE 21 -50 YEARS  SEX M>F  RESIDENCE  SOCIOECONOMIC STATUS  OCCUPATION  SEASONS (3:1) RURAL >URBAN LOW > HIGH FARMERS, LABOURER. AUTUMN, RAINY. Cornea 2000; August:555-59
  • 18. PREDISPOSING FACTORS • Trauma vegetable matter metallic foreign body sand/stone • Chronic topical medication • Diabetes Mellitus • Topical or systemic corticosteroids • Extended wear/bandage contact lens • Penetrating keratoplasty • Anterior uveitis • Herpes simplex keratitis
  • 19. ETIOPATHOGENESIS Over 70 genera can cause mycotic keratitis  Fungi of importance in microbial keratitis  Moniliaceae -- Aspergillus (90%) Most common cause in World -- Fusarium(1%)Second most common cause --Paecilomyces. --Penicillium. --Pseudallescheria.  Data in brackets from Dept of ophtahlmology, PGIMER
  • 20. CONTD.. • Dematiaceae. --Curvalaria. (2%) --Alternaria. --Phialophora. --Bipolaris. --Exserohilum. --Cladosporium. -- Colletotrichum • Yeast. --Candida. (2.5%) --Cryptococcus • Dimorphic fungi. --Blastomyces. --Coccidioides. --Histoplasma. --Sporothrix.
  • 22. • PATHOGENESIS -Breach in epithelium -Compromised cornea -Immunocompromised Contact of fungal hyphae with cornea Filamentous Yeast
  • 23. FUNGAL ADHERENCE  Filamentous Fibrinogen receptors on mature conidia of aspergillus and fusarium  Yeast Integrin analogue, Fibronectin receptor, Adhesive mannoprotn, Aspartyl proteinase, Factor 6 , Endo. adhesions.
  • 24. PENETRATION  Filamentous fungi: Parallel growth of hyphae to stroma, f/b release of mycotoxins, proteolytic enzymes, soluble fungal antigen  Yeast: Proliferate parallel & perpendicular to corneal stroma f/b release of protease and lipase
  • 25. HOST RESPONSE FILAMENTOUS inablity of PMN,leucocyte cell for phagocytosis destruction of corneal stroma penetrate descement membrane enterAC accumulate around lens seclusion of pupil fungal glaucoma
  • 26. HOST RESPONSE YEAST inability of PMN cell to ingest pseudohyphae and hyphae furstated phagocytosis by PMN destruction of stroma melting of cornea
  • 27. CLINICAL FEATURES • • • • • Signs >> symptoms Manifest within 24 – 48 hours Patient present within 1st week EARLY BI-MICROSCOPIC FINDING Fine or coarse granular infiltrate within the epithelium and anterior stroma • Minimal stromal infiltrate • Epithelial surface is dry rough textured, dirty gray in color
  • 28. CONT……… • Epithelium may be intact or ulcerated. • Pigmented and delicate ,feathery branching hyphae with surrounding infiltrate • Multifocal suppurative microabsscess or satellite lesion
  • 29. CONTD…. • Advanced lesions o Dense fibrinous material adhering to endothelium and iris o Total stromal infiltrate and necrosis
  • 30. CONTD………….. • • • • • • • Other signs White ring (Wessely`s ring) Conjunctival hyperemia AC reaction Hypopyon endothelial plaque Mild iritis
  • 31. YEAST KERATITIS • Risk Fatcors • Previously compromised cornea • SYSTEMIC DISEASE Sjogren’s syndrome Erythema multiforme IgA deficiency HIV Endocrinopathy
  • 32. CLINICAL FEATURE OF CANDIDA INFECTION • Ulcer is small oval with expanding discrete sharply demarcated ,dense yellow –white stromal suppuration • Feathery margins are not seen
  • 33. FUNGAL ENDOPHTHALMITIS  a suppurative inflammation of inner ocular coats and their adjacent structure  with involvement of anterior chamber and vitreous fluid,  caused by various fungal agents
  • 34. FUNGAL ENDOPHTHALMITIS  Clinically two types  Endogenous due to hematogenous spread  Exogenous due to trauma or post operative
  • 35. EPIDEMIOLOGY  The first description of endogenous fungal endophthalmitis was by Dimmer in 1913  Candida endopthalmitis clinical entity in 1958  In U.S.A. compared to previous decades Endophthalmitis Increase from last few decades.  Incidence is increasing because of modern medical practices  USA 30 % candidemia(Last 3 decdes) develop endopthalmitis, now there is a lower incidence because of prophylacyic antifungals CMR, October 2000, p. 662–685
  • 36. PATHOGENESIS ENDOGENOUS  Multifactorial.  It is likely that sustained fungemia with even saprophytic fungi can lead to endopthalmitis Gupte et al -contaminant IV fluids,11 / 72 IV fluid samples culture positive for fungi  At the time of initial infection with some dimorphic, fungi, such as H. capsulatum & C. immitis, unrecognized fungemia occurs and often leads to endophthalmitis.
  • 37. ENDOGENOUS ENDOPHTHALMITIS  Predisposing factors  Systemic debilitating disease  Malignancy  IVDU  Chemotherapy  Systemic antibiotics  Alcoholism &  Diabetes
  • 38. PATHOGENESIS ENDOGENOUS  More common in immunocompromised ie pts on chemo or IV drug abuse  Marked trophism for eye because peculiar blood supply of the eye.
  • 39. PATHOGENESIS: EXOGENOUS  Occurs in immunocompetent people  Direct introduction of the organisms following  Surgery(Catarct removal with placement of IOL mainly Candida spp)  Trauma(Mainly Fusarium spp. )  I/O spread from Fungal keratitis
  • 40. EPIDEMIOLOGY  RACE – no racial preponderance  SEX – Male preponderance (3:1)  AGE – Young and middle age.
  • 41. MORBIDITY  Prognosis     depends upon virulence of organism extent of involvement timing mode of intervention  Prompt therapy following early diagnosis helps to reduce visual loss  Visual outcome of aspergillus endo. is poor d/t macular involvement.
  • 42. AGENTS Endogenous Endotphthalmitis  Candia albicans  Fusarium species  Aspergillus species  Histoplasma capsulatum  Coccidioides immitis  Blastomyces dermatitidis  Cryptococcus neoformnas
  • 43. C. ALBICANS  M.C.C of endogenous endopthalmitis  Infection usually starts from Choroid and then spreads to retina  Non candida albicans fungemia & endopthalmitis is increasing and is concern because of antimicrobial resistance
  • 44. CANDIDIAL ENDOPTHALMITIS Current Eye Research, 1–11, Early Online, 2010
  • 45. ASPERGILLUS ENDOPTHALMITIS  A. flavus second MCC  Spreads from lungs to eye  This is f/b A. fumigatus, A. niger, A. terreus, A. glaucus , & A. nidulans .
  • 46. CRYPTOCOCCAL ENDOPH.  Cryptococci spores survive in pigeons dropping  From lung, fungus – disseminated haematogenesouly and can affect CNS causing fungal meningitis & endophthalmitis in eye  Choroids is the probably first site of ocular infections
  • 47. AGENTS Exogenous Endophthalmitis Aspergillus spp.  C. albicans,C. glabrata, C. tropicalis, C. parapsilosis  Paecilomyces spp.  Fusarium spp.  Acremonium spp.  Curvularia spp. 
  • 48. PRESUMED OCULAR HISTOPLASMOSIS  Occurs in immunocompetent individuals  Recognized by presence of multiple atrophic chorioretinal scars w/o vitreous or aqueous humor inflmn.  Affect 2,000 new individuals a year in areas of endemicity and in some cases may lead to visual loss and blindness  Arises from hematogenous spread  Not detectable in the scars of POH  Strong epidemiological evidence, principally deriving from skin test surveys, linking the scars to histoplasmosis
  • 49. CLINICAL FEATURES Symptoms Visual loss  Pt. may be asymptomatic if the lesion is in the peripheral retina  Red eye.  Photophobia.  Pain.  Floaters.  Scotoma 
  • 50.  Many have a classical appearance with progressive granulomatous uveitis  diffuse retinitis  deep vitreous abscess.   Time to make diag. from onset of symptoms, 3 d to 4 months.
  • 53. PERIOCULAR INFECTIONS Agent  Palpebral Aspergillosis Blastomycosis involvement No of cases in literature 2 12 As a part of generalized or local disease 3 C. albicans  First reported case  1922 case of sporotrichosis 6 Coccidioidomycosis  3 Cryptococcus spp.  Tinea faciale 11 Dermatophyte  Aspergilloma, sporotrichosis  Chalazion 5 Paracoccidioidomycosis 7 Rhinosporidiosis  Blastomycosis, Coccidioidomycosis  Basal cell carcinoma 5 Sporothrix spp.
  • 54. INFECTIONS OF THE LACRIMAL GLAND  Fungi found to account for only 5% of infections .  14% of cases of congenital dacryocystitis  Principally Aspergillus spp. and C. albicans implicated  Epiphora is only clinical finding  Lid edema, conjunctival injection, and swelling in the medial canthus; pressure over the area usually results in a purulent discharge through the lower punctum Thomas, CMR, Oct 2003,
  • 55. FUNGAL INFECTIONS OF ORBIT Proximity of sinuses to orbit, susceptible host & pathogen  Zygomycosis  Rhinoorbitocerebral : one-third to one-half of all cases, Incidence increasing  Major risk factor : uncontrolled diabetes mellitus(70% DKA)  Other predisposing factors        Chronic alcoholism Renal transplantation Hematological malignancies Steroid therapy Breach of skin Starts with symptoms consistent with sinusitis Bloody nasal discharge  Diplopia and loss of vision Chakrabarti et al., 2006
  • 56. INFECTIONS OF ORBIT  Invasive aspergillosis  Increased frequency infection :widespread prophylaxis with fluconazole [VanBurikJH et al. The effect of prophylactic fluconazole on the clinical Spectrum of fungal diseases in bone marrow transplant recipients with special attention to hepatic candidiasis.Medicine(Baltimore) 1998;77:246−54.]  Exact prevalence of invasive aspergillosis in India is not known [Chakrabarti et al , Japanese Journal of Medical Microbiology vol 49, 165-72, 2008]
  • 57. INVASIVE ASPERGILLOSIS  Other fungi mimicking aspergillosis Bipolaris spp.  Alternaria spp.  Curvularia spp.  C. immitis  B. dermatitidis  Histoplasma spp.  Penicillium spp.   C/F orbital inflammation & a red proptotic eye with or without associated pain  ophthalmoplegia may develop  Embolization of vessels of the optic nerve, or direct involvement of the nerve may occur 
  • 58. FUNGAL CONJUNCTIVITIS     Can occur indepently or with keratomycosis Clinically rare entity Fungi may be present without causing inflammation in~ 25% pts Topical application tetracycline X 4 wks increased prevalence 28.7% [Nema, H.V., O.P. Ahuja, A. Bal and L.N. Mohapatra, Effects of topical corticosteroids and antibiotics on mycotic flora of conjunctiva. Am. J. Ophthal., 1968. 65: p. 747–750].  Topical applications of corticosteroids X 3 wks increase prevalence of fungi 18.8-67% [Mitsui, Y. and J. Hanabusa, Corneal infections after cortisone therapy. Br. J.Ophthal., 1955. 39: p. 244–250.]   C. albicans follows steroid LA  Pseudomembrane Other organisms Aspergillus, Blastomycosis, Sporothrix, Coccidiodomycosis
  • 59. EXPERIMENTAL MODELS FK  Albino, wild rabbit , Dutch belted rabbit  Previously immunocompromised   Fractionated cobalt whole-body radiation  administration of antilymphocyte serum   corticosteroids locally or systemically alloxan-induced diabetes Intra lamellar injection or Superficial inoculation of spore suspension
  • 60. CONTD..  IL inoculation :  C. albicans, C. krusei, C. tropicalis, C. pseudotropicalis, Aspergillus spp., Cephalosporium spp., F. solani, Lasiodiplodia sp.  Superficial inoculation:  C. albicans, C. tropicalis, C. pseudotropicalis, Aspergillus spp., Allescheria boydii, Cephalosporium spp., Geotrichum sp.  Antibacterial prophylaxis & use of characterized strain ensures reproducibilty.  IO penetration of ketokonazole in rabbit has been tried as a therapeutic modaliities
  • 61. OTHERS  Mice BALB/c mice  ip cyclophosphamide 180 mg/kg 1,3, & 5d  Scarified corneas /keratoplasty rat cornea in b/w space  topically inoculated  Easy handling   Rat Wistar rats or Lewis rats  Suitable size & immune response  Size of eyes better surgical manipulation   Pigs   Large size, ease of fitting contact lens Owl monkeys  Not better than Rabbit keratomycosis model
  • 62. ENDOPHTHALMITIS MODELS  Rabbits Both immunocompetent and immunocompromised rabbits are used  Used mainly for endogenous endophthalmitis  0.5 ml of 2 X 107 org/ ml into auricular vein  intravitreal inoculation of 1,000 CFU of susceptible C. albicans  Junko et al Jpn. J. infect. Dis., 60, 33-39, 2007  Mice Fusarium solani in immunocompetent mice  Inocula of 5 x 10(6) conidia  injected into the lateral tail vein  Mayayo et al Med Mycol. 1998 Oct;36(5):249-53
  • 65. LABORATORY DIAGNOSIS  Sample collection and transport       Biopsy Corneal scraping, corneal button AC tap Vitreous tap Fluids Lens  Swabs not encouraged  Sterile leak proof container ASAP  Delay 4°C with exception of blood and vitreous (30-37°C ) & swab (15%)
  • 66. SAMPLES  Detailed examination of affected eye using slit lamp  Tissues diagnostic material harvested by experienced ophthalmologist after LA or SA Biopsy  Scraping :15 Bard – parker surgical blade from the base & margin(thoroughly) of ulcer aseptically or Kimura’s platinum spatula  Impression smear(Jain et al 2006 – PGIMER, Chandigarh – equally sensitive and specific as Scrappings)  Vitreous tap 300 microL using 23 G needle  Aqeous tap 200 microL using 23 G needle 
  • 67. CONVENTIONAL TECHNIQUES  Direct microscopy Rapid and cost effective  10% KOH preparation  Gram & Geimsa stain  Calcoflour Stain – Easy and fast  H&E, GMS, PAS, cytologic preparation   Culture SDA, Blood agar,  CHROM agar   Susceptibility testing  According to CLSI guidelines
  • 68. CONVENTIONAL  Nonspecific fluorescent stain – {calcoflour white, blankophor, uvitex 2B} –  used in tissue sections and  cytopathologic preparation of rapid diagnosis of mycotic infections.  Chander et al. Sensitivity of Calcofluor white – 95.2% compared to 71.4 % for KOH and culture.  fluorescent microscope  wavelength of 365 nm.  Acridine orange staining – useful in early diagnosis of keratomycosis  PAS (Periodic acid schiff) stain can also use.
  • 69. CULTURE  Corneal scraping inoculated on agar plate as a ‘C’ or ‘S’ shaped streak incubated at 25 & 37°C X 4wks  Fungal growth in the form of the streak ensure that the growth is from the inoculum / specimen rather than a laboratory contaminant.  Two sets of SDA with antibiotic, inoculated and incubated at 250 C & 370C separately x 4 wks. Keeping a possibility of dimorphic fungi
  • 70. CULTURE  Vitreous fluid inoculated on routine fungal culture media .  Vitreous sample should be concentrate either by   centrifugation Millipore filtration
  • 71. CULTURE  All the culture checked everyday during first week and  twice a week during next 3 week weeks.   Positive culture are more convincing  when growth is obtained on more than one occasion.
  • 73. MOLECULAR TECHNIQUES  PCR based detection methods  PCR Rapid molecular identification of fungal pathogens in corneal samples from suspected keratomycosis cases. J Med Microbiol. 2006 Nov;55(Pt 11):1505-9.  PCR - SSCP Sensitive and rapid polymerase chain reaction based diagnosis of mycotic keratitis through single stranded conformation polymorphism. Am J Ophthalmol. 2005 Nov;140(5):851-857.  Nested PCR Comparative study of Gram stain, potassium hydroxide smear, culture and nested PCR in the diagnosis of fungal keratitis. Ophthalmic Res. 2010;44(4):251-6.
  • 74. MOLECULAR TECHNIQUES  PCR-RFLP Diagnosis of Aspergillus fumigatus endophthalmitis from formalin fixed paraffinembedded tissue by polymerase chain reaction-based restriction fragment length polymorphism Indian J Ophthalmol. 2008 Jan-Feb;56(1):65-6.  Real time quantitative PCR Detection and quantification of pathogenic bacteria and fungi using real-time polymerase chain reaction by cycling probe in patients with corneal ulcer. Arch Ophthalmol. 2010 May;128(5):535-40.
  • 75. PRINCIPLES OF TREATMENT  As with any other fungal infection , look & treat for any predisposing illness  Confirm lab diagnosis  Look for and treat any superadded infection  Remember  Poor penetration of antifungal drugs  Corticosteroids are contraindicated  Use both surgical and medical approach whenever needed  Close follow up is required
  • 76. FUNGAL KERATITIS  Superficial (early keratitis): Topical natamycin (5%) (hyphae)  Topical 0.15% amphotericin B or topical fluconazole (yeasts)  Debridment of the epithelium   Deeper and larger lesions: Subconjunctival or intravenous miconazole  Ketoconazole, itraconazole, fluconazole or voriconazole (p.o.)  Intracameral amphotericin B   Surgical treatment: Cyanoacrylate tissue adhesive  Amniotic membrane transplantation  Penetrating keratoplasty 
  • 77. ENDOGENOUS ENDOPHTHALMITIS  Systemic antifungal agents: Fluconazole, voriconazole (azole compounds)  Systemic antifungal agents: Amphotericin B: Parenteral ± intravitreal  Pars plana vitrectomy
  • 78. EXOGENOUS ENDOPHTHALMITIS    Intraocular (intracameral ± intravitreal) amphotericin B Intravitreal voriconazole or miconazole Subconjunctival antifungal agents: when associated with keratitis  Systemic antifungal agents: fluconazole, ketoconazole, voriconazole, itraconazole, m iconazole, and amphotericin B: important in immunocompromised patients  Pars plana vitrectomy
  • 79. MUCORMYCOSIS  Radical surgery+ antifungal therapy + correcting underlying conditions  Amphotericin B Ist DOC(Amphotericin B given IV at a daily dose of 1.0-1.5 mg/kg infused during 2-4 hr for a total of 1-4 g)  Lipid formulations of amphotericin B alternative Ferri: Practical Guide to the Care of the Medical Patient, 8th ed
  • 80. INVASIVE ASPERGILLOSIS  Voriconazole 6 mg/kg IV q12h for 2 doses, then 4 mg/kg q12h PO Rx for adults is 200 mg bid or 4 mg/kg bid.  Caspofungin in pts who fail to respond to or are unable to tolerate other antifungal drugs. The recommended dosage is 70 mg on the first day and 50 mg qd thereafter given as a single dose IV over 1 hr. Ferri: Practical Guide to the Care of the Medical Patient, 8th ed
  • 81. Even though we cannot live forever, let our eyes live and give sight for the needy! I have pledged my eyes, you can do that too..

Hinweis der Redaktion

  1. Pt of mucorycosis, CT left Mucormycosis of LE, Rt invasive aspergillus eroding Lamina papyracea, Autopsy sphenoid pus which showed