Fungal Ulcer- Diagnosis and Management!

𝘍𝘶𝘯𝘨𝘢𝘭 𝘜𝘭𝘤𝘦𝘳- 𝘋𝘪𝘢𝘨𝘯𝘰𝘴𝘪𝘴 𝘢𝘯𝘥 𝘔𝘢𝘯𝘢𝘨𝘦𝘮𝘦𝘯𝘵⁣

The picture shows a KOH mount showing filamentous septate hyphae ⁣




𝗗𝗶𝗮𝗴𝗻𝗼𝘀𝗶𝘀:⁣

● Corneal scraping- both diagnostic and therapeutic⁣

● AC tap⁣

● Corneal biopsy⁣

● PCR⁣

● Confocal microscopy ⁣

𝗦𝘁𝗮𝗶𝗻𝘀 𝘂𝘀𝗲𝗱:⁣

● KOH mount with Calcoflour white⁣

● Gram’s stain⁣

● Giemsa stain⁣

● Lactophenol cotton blue⁣

● PAS stain⁣

● Grocott’s Methenamine-silver stain⁣

𝗙𝘂𝗻𝗴𝗮𝗹 𝗰𝘂𝗹𝘁𝘂𝗿𝗲:⁣

● Sheep blood agar⁣

● Chocolate agar⁣

● Sabouraud dextrose agar (without cycloheximide) - should contain 50⁣

micrograms /ml gentamicin and should be without cycloheximide as the latter⁣ inhibits saprophytic fungi.⁣

● Thioglycollate broth - possible growth of anaerobic bacteria at 35 C to 37 C.⁣

● Brain heart infusion⁣

𝘈 𝘥𝘦𝘧𝘪𝘯𝘪𝘵𝘪𝘷𝘦 𝘥𝘪𝘢𝘨𝘯𝘰𝘴𝘪𝘴 𝘰𝘧 𝘧𝘶𝘯𝘨𝘢𝘭 𝘬𝘦𝘳𝘢𝘵𝘪𝘵𝘪𝘴 𝘪𝘴 𝘮𝘢𝘥𝘦 𝘪𝘧⁣

1. Corneal scrapings reveal fungal elements in smears.⁣

2. Fungus grows in more than one medium in the absence of fungus in smears.⁣

3. Fungus grows on a single medium in the presence of fungus in smears.⁣

4. Confluent growth of fungus appears at the inoculated site on a single solid⁣

medium.⁣

Initial growth occurs within 72 hours.⁣


⁣𝗠𝗮𝗻𝗮𝗴𝗲𝗺𝗲𝗻𝘁:⁣

𝗠𝗲𝗱𝗶𝗰𝗮𝗹:⁣

● Topical antifungal agents⁣

Natamycin 5% suspension – initial choice⁣

Topical amphotericin 0.15% in cases of Candida/Aspergillus Fluconazole 0.3%/Miconazole/Voriconazole in cases of Fusarium⁣

● Intracameral Amphotericin B- 5 ug in 0.1ml 5% dextrose⁣

● Intrastromal therapy Amphotericin B 5-7.5 ug⁣

● Subconjunctival injection in cases of scleritis⁣

● Systemic antifungals (eg. Ketoconazole) given in:

Severe deep keratitis

Limbal involvement

Scleritis, Endophthalmitis

Prophylactic after TPK

Virulent fungus⁣


● Cycloplegics⁣

● Anti glaucoma drops if IOP is high⁣

𝗦𝘂𝗿𝗴𝗶𝗰𝗮𝗹:⁣

● Debridement- Debulks organisms & necrotic material and enhances penetration of topical antifungals. Every 24-48 hours.⁣

● Biopsy⁣

● Conjunctival flaps⁣

● Therapeutic keratoplasty:⁣

When progression is noted and involves limbus/sclera⁣

Endophthalmitis

Impending perforations/frank perforations

No response to therapy⁣


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