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Fungal Ulcer- Diagnosis and Management!

๐˜๐˜ถ๐˜ฏ๐˜จ๐˜ข๐˜ญ ๐˜œ๐˜ญ๐˜ค๐˜ฆ๐˜ณ- ๐˜‹๐˜ช๐˜ข๐˜จ๐˜ฏ๐˜ฐ๐˜ด๐˜ช๐˜ด ๐˜ข๐˜ฏ๐˜ฅ ๐˜”๐˜ข๐˜ฏ๐˜ข๐˜จ๐˜ฆ๐˜ฎ๐˜ฆ๐˜ฏ๐˜ตโฃ

โฃ

The picture shows a KOH mount showing filamentous septate hyphae โฃ




โฃ

๐——๐—ถ๐—ฎ๐—ด๐—ป๐—ผ๐˜€๐—ถ๐˜€:โฃ

โ— Corneal scraping- both diagnostic and therapeuticโฃ

โ— AC tapโฃ

โ— Corneal biopsyโฃ

โ— PCRโฃ

โ— Confocal microscopy โฃ

โฃ

๐—ฆ๐˜๐—ฎ๐—ถ๐—ป๐˜€ ๐˜‚๐˜€๐—ฒ๐—ฑ:โฃ

โ— KOH mount with Calcoflour whiteโฃ

โ— Gramโ€™s stainโฃ

โ— Giemsa stainโฃ

โ— Lactophenol cotton blueโฃ

โ— PAS stainโฃ

โ— Grocottโ€™s Methenamine-silver stainโฃ

โฃ

๐—™๐˜‚๐—ป๐—ด๐—ฎ๐—น ๐—ฐ๐˜‚๐—น๐˜๐˜‚๐—ฟ๐—ฒ:โฃ

โ— Sheep blood agarโฃ

โ— Chocolate agarโฃ

โ— Sabouraud dextrose agar (without cycloheximide) - should contain 50โฃ

micrograms /ml gentamicin and should be without cycloheximide as the latterโฃ inhibits saprophytic fungi.โฃ

โ— Thioglycollate broth - possible growth of anaerobic bacteria at 35 C to 37 C.โฃ

โ— Brain heart infusionโฃ

โฃ

๐˜ˆ ๐˜ฅ๐˜ฆ๐˜ง๐˜ช๐˜ฏ๐˜ช๐˜ต๐˜ช๐˜ท๐˜ฆ ๐˜ฅ๐˜ช๐˜ข๐˜จ๐˜ฏ๐˜ฐ๐˜ด๐˜ช๐˜ด ๐˜ฐ๐˜ง ๐˜ง๐˜ถ๐˜ฏ๐˜จ๐˜ข๐˜ญ ๐˜ฌ๐˜ฆ๐˜ณ๐˜ข๐˜ต๐˜ช๐˜ต๐˜ช๐˜ด ๐˜ช๐˜ด ๐˜ฎ๐˜ข๐˜ฅ๐˜ฆ ๐˜ช๐˜งโฃ

1. Corneal scrapings reveal fungal elements in smears.โฃ

2. Fungus grows in more than one medium in the absence of fungus in smears.โฃ

3. Fungus grows on a single medium in the presence of fungus in smears.โฃ

4. Confluent growth of fungus appears at the inoculated site on a single solidโฃ

medium.โฃ

Initial growth occurs within 72 hours.โฃ


โฃ๐— ๐—ฎ๐—ป๐—ฎ๐—ด๐—ฒ๐—บ๐—ฒ๐—ป๐˜:โฃ

๐— ๐—ฒ๐—ฑ๐—ถ๐—ฐ๐—ฎ๐—น:โฃ

โ— Topical antifungal agentsโฃ

Natamycin 5% suspension โ€“ initial choiceโฃ

Topical amphotericin 0.15% in cases of Candida/Aspergillus Fluconazole 0.3%/Miconazole/Voriconazole in cases of Fusariumโฃ

โ— Intracameral Amphotericin B- 5 ug in 0.1ml 5% dextroseโฃ

โ— Intrastromal therapy Amphotericin B 5-7.5 ugโฃ

โ— Subconjunctival injection in cases of scleritisโฃ

โ— Systemic antifungals (eg. Ketoconazole) given in:

Severe deep keratitis

Limbal involvement

Scleritis, Endophthalmitis

Prophylactic after TPK

Virulent fungusโฃ


โ— Cycloplegicsโฃ

โ— Anti glaucoma drops if IOP is highโฃ

โฃ

๐—ฆ๐˜‚๐—ฟ๐—ด๐—ถ๐—ฐ๐—ฎ๐—น:โฃ

โ— Debridement- Debulks organisms & necrotic material and enhances penetration of topical antifungals. Every 24-48 hours.โฃ

โ— Biopsyโฃ

โ— Conjunctival flapsโฃ

โ— Therapeutic keratoplasty:โฃ

When progression is noted and involves limbus/scleraโฃ

Endophthalmitis

Impending perforations/frank perforations

No response to therapyโฃ


www.ophthalmobytes.com


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