The Diagnosis and of Keratomycoses I. Cause and
Management
Diagnosis
Richard K. Forster, MD, Gerbert
Rebell, MS
\s=b\ Causative isolates, clinical features, and laboratory studies are reported for sixty-one cases of culture-proved mycotic keratitis. Isolates are categorized into four groups, including 36 Fusarium solani, 11 other Moniliaceae species, seven Dematiaceae, and seven yeasts. Of the 61 patients, 42 were men. Mild outdoor trauma was sustained in 14 of 24 cases. Patients were often referred with a clinical diagnosis of presumed fungal keratitis, within one week of symptom development, and usually had not received topically applied steroids prior to referral. Laboratory diagnosis necessitates prompt corneal scrapings, preferably stained with Giemsa or Gram, and culture on Sabouraud and blood agar maintained at room temperature, with growth usually evident by 48 hours.
(Arch Ophthalmol 93:975-978, 1975)
diagnostic Clinical fungal increasing reported and istics of
character¬ keratitis have fre¬ been with quency during the last ten years.1-7 In the past five years, we have investi¬ gated 61 cases, in addition to the first 38 culture-proved cases reported from this institute.1 By providing identi¬ fication of keratitis isolates and per¬
forming sensitivity studies, we have also collected, lyophilized, and later studied fungal strains from other parts of the United States, South America, Europe, and Asia. The purpose of this report is to evaluate the specific causes, clinical features, and laboratory diagnosis of fungal keratitis in our latest 61 cases, to augment or shift the emphasis of certain impressions, and to provide a useful guide to be followed by prac¬ ticing ophthalmologists and mycologists.
SUBJECTS AND METHODS Patients
Sixty-one patients with culture-proved fungal keratitis were examined by us be¬ tween July 1969 and July 1974, on a private referral basis or from the resident service at the Bascom Palmer Eye Institute. Clini¬ cal and laboratory data from these cases were compared with 38 previously reported cases from the Bascom Palmer Eye Insti¬ tute studied prior to July 1969.3
Clinical and
Laboratory Diagnosis
All cases had culture confirmation from either corneal scrapings or keratoplasty specimens. Sabouraud agar consisted of dextrose-peptone agar with yeast extract and 50jug/ml gentamicin sulfate, without cyclohexamide, and held at room tempera¬ ture. Sheep-blood agar was inoculated and held at both room temperature (25 C) and body temperature (37 C). The liquid media consisted of brain-heart infusion (BHI) with gentamicin, 50|iig/ml, maintained on a rotary shaker (about 200 rpm) at room
temperature.
Submitted for publication July 26, 1974. From the Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami School of Medicine, Miami, Fla. Reprint requests to Department of Ophthalmology, University of Miami School of Medicine, PO Box 875, Biscayne Annex, Miami, FL 33152
(Dr. Forster).
Material from corneal scrapings was ex¬ amined by Giemsa and Gram stains, and 20% potassium hydroxide preparations. Corneal fragments obtained from surgery were examined histopathologically by Gomori methenamine silver or PAS reac¬ tions.
Isolate Identification An attempt
Downloaded From: http://archopht.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015
was
made to determine the
species of all keratitis strains us (G.R.). Fusarium species were identified according to the taxonomic guides of Snyder and Hansen5 and Booth," and some strains were personally con¬ firmed by Snyder or Nelson; other Moniliaceae were identified by the methods of Von Arx,"1 Gams," and periodical litera¬ ture; Dematiaceae species were identified by the Ellis classification,'-' and also were sent directly to Ellis for confirmation. genus and by one of
RESULTS Identification of Isolates The 61 isolates were arranged ac¬ cording to four convenient diagnostic and laboratory groups. Fusarium so¬ taní was isolated in 36 cases. Other Moniliaceae, which are nonpigmented filamentary fungi, including other species of Fusarium, accounted for 11 cases. Dematiaceae, which are pig¬ mented filamentary fungi, were iso¬ lated in seven cases. Yeasts ac¬ counted for seven isolates. If we combine the 38 cases reported by Jones1' from this institute, which cover the ten years prior to July 1969, there are a total of 99 isolates. Clinical Features
of the patients under the age of 50 years, and 28% were less than 30 years old. Of the 61 patients, 42 were men, com¬ pared to 19 women. A history of defi¬ nite local foreign-body trauma was obtained in 24 cases, and possible trauma in another five cases. The im¬ portance of outdoor or plant material (14 of 24), and frequent outdoor occu¬ pations or hobbies was evident. Octo¬ ber through April was the most fre¬ quent season of occurrence.
Fifty-seven percent
were
Steroid and Antibiotic Treatment In
only
four
cases was
there
a
his¬
tory of steroid or antibiotic use before the development of symptoms. After the development of symptoms, but
before the diagnosis of fungal kera¬ titis was confirmed, 33 patients were given antibiotics and 15 received topi¬ cal applications of steroids, including 12 with both. Definitely no antibiotics were used in 21 cases, and no steroids in 38.
Referring Diagnosis The correct
diagnosis of "suspected
fungus ulcer" was made in 19 of 33 private patients (58%). Herpes kera¬ titis was suspected in seven of 14 "missed" diagnoses. Over one half of the cases (32 of 61) were seen within one
week of symptom onset.
Appearance The clinical appearance was vari¬ but one or more of the features described by Kaufman and Wood1 were present in all cases, including slightly elevated, shaggy ulcers with hyphal stromal infiltrates surround¬ ing the ulcer, and occasionally satel¬ lite lesions, "rings," endothelial plaques, and hypopyons (Fig 1).
able,
Laboratory Corneal scrapings
with
Results
obtained after the ap¬
were
platinum spatula plication of proparacaine hydrochlo¬ ride topically, and with the aid of slit lamp microscopy. Repeated scrapings were made from the base and edges of the ulcers and were placed on Sa¬ bouraud agar, two blood agar plates, a
in brain-heart infusion broth, and placed on at least three slides to be prepared for KOH, Gram, and Giemsa stains examination. Microscopic Examinations of Scrap¬
ings.—The KOH preparation was posi¬ tive in nine cases; the Gram stain pos¬ itive in 28 cases; the Giemsa stained scraping positive in 33 cases. In 34 of the cases, all three preparations were examined. In no case was the KOH positive, with a negative Gram and Giemsa stain. Cultures.—Culture results were con¬ sidered from 69 scrapings, consisting of the 61 cases plus one culture-nega¬ tive case that had a definite positive scraping by Gram and Giemsa stains, and seven positive repeat cultures that were performed in cases initially culture positive. Of the 69 cultures, 60 were positive on Sabouraud agar; 49 were positive on liquid BHI. Since not all cases were cultured on the three media, it is probably more important to examine the media that had nega¬ tive cultures but that were positive on at least one media. There were nine negative cultures on Sabouraud agar, nine on room temperature blood agar, and 22 on BHI liquid broth. Blood agar at
body temperature (37 C)
was
positive in 36 cases and negative in 17 Most isolates grew rapidly and growth was detected by 36 to 48 hours after scrapings (Fig 2). cases.
COMMENT
Certain generalizations and de¬ scribed features of fungal keratitis may be incorrect, may need modi¬ fication, or should be stressed in order
improve the clinical-laboratory diagnosis. Our experience with 61 to
in the past five years has rein¬ forced those features that aid in more frequent recognition and causative cases
diagnosis.
Rather than consider these cases under the general diagnosis of keratomycoses, we have chosen to divide them into four major arbitrary groups of frequently encountered iso¬ lates. These consist of the following: (1) F solani; (2) other Moniliaceae; (3) Demetiaceae; and (4) yeasts. Al¬ though subtle differences in appear¬ ance and clinical features may be noted, the other differences between these groups lie in culture and mor¬
phologic characteristics, sensitivity studies to antifungal agents, and fre¬
quency of occurrence as causes of fungal keratitis. Fusarium solani was the major species of fungus in the first 38 cases reported from the Bascom Palmer Eye Institute,·1 was isolated by us in 18 consecutive cases treated with na¬
tamycin (pimaricine),7 was the causa¬ tive agent in 36 of 61 cases in this re¬ port, and accounted for about 50% of all keratitis strains sent to us for identification from other parts of the United States and South America. The second group consists of Mo¬ niliaceae other than F solani. This group may be the least homogenous and have the greatest number of spe¬ cies, but altogether, in 99 cultureproved cases in the files of the Bas¬ com Palmer Eye Institute, accounted for 15 isolates, including 11 of 61 cases in this series. The fungi in the third group are the Dematiaceae and other pigmented fungi. Curvularia, Alternaría, Drechslera, and Lasiodiplodia theobromae, which we are for convenience
including in this group, have been en¬ countered repeatedly in our collec-
Downloaded From: http://archopht.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015
1 .—Clinical appearance of F solani keratitis. Top left, Dense infiltrate with hyphal margins. Top right, Fluffy feathery borders. Bot¬ left, Nodular and satellite lesions. Bottom right, Pseudopodes and "ring" infiltrates.
Fig tom
stain. Top center, Giemsa stain. Sabouraud agar. Bottom center, Growth of F solani shaker.
Fig 2—Top left, Gram
on
Top right, Potassium hydroxide wet preparation. Bottom left, Growth of F solani on blood agar (25 C). Bottom right, Round colonies in liquid BHI from rotary
Downloaded From: http://archopht.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015
tion. The fourth group are the yeasts. These seem to occur more frequently in "sick" eyes, particularly on chronic use of steroids and antibiotics. The concept that fungal ulcers de¬ velop in older patients with debilitat¬ ing diseases or prior corneal dis¬ orders, or that most have been treated with steroids or antibiotics for indolent ulcers is not borne out by our experience. These are by and large, with the exception of the yeasts, primary infections of the cornea that are apparently intro¬ duced by minor trauma. One fourth of the patients in this series were under 30 years of age (57% under 50), and 70% were men. Cases occurred as young as 2lk and as old as 86 years. Definite trauma was experienced in 24 cases (40%), with 14 of these occurring outdoors from plant matter, dirt or stones. Although most of the patients had no prior ocular difficulties, four cases developed in patients with abnormal corneas, including three due to Can¬ dida albicans. Only two of the 61 pa¬ tients used prior topically applied steroids or antibiotics before the de¬ velopment of fungal keratitis. While the seasonal peak was in the spring and no cases developed in the months of June through September in the first series of 38 cases3; in this re¬ view of 61 cases, the onset peaked from October through April, and a to¬ tal of 13 cases developed in the months of June through September. It should be noted, however, that the peak incidence correlates with windy,
cool, and drier weather during the
months of October through April in South Florida. Awareness and a high index of sus¬ picion of fungal keratitis has ac¬ counted for a higher number of cor¬ rect referral diagnoses and the withholding of steroids following un¬ determined or outdoor trauma. Only one fourth (15 of 61) of the patients received steroids after the develop¬ ment of symptoms. This was also at¬ tested to by the prompt referral for diagnostic studies and specific antifungal management, with 33 of 61 cases initially cultured within one week of the onset of symptoms. In this study, the Giemsa and Gram stains were more reliable than the KOH preparation, and provided a permanent mount. Gomori methenamine silver or PAS histopathology of corneal fragments are sufficient for
surgical specimens. The use of multiple media will give the highest yield of positive cultures.
Sabouraud agar is probably most re¬ liable if it is available without cyclohexamide, which inhibits many of the fungi that cause keratitis. However, fresh blood agar should be considered nearly as reliable. Bacterial contami¬ nants have not been a problem, par¬ ticularly if incubated at room tem¬ perature (25 C). Usually confirmation of the presence of fungi can be made within 48 hours.
This study was supported in part by Public Health Service grant 5 ROI EY00674-2 from the National Eye Institute; Fight For Sight, Inc., grant G457; United Health Foundation of Dade
County; the Florida Lions Eye Bank; and the Flournoy and Mae Knight Clark Research Fund. Maria Suerio and Mary G. Wirta provided
technical assistance.
Key Words.—Fungal keratitis, keratomysolani, Moniliaceae fungi, Dematiaceae fungi, yeasts, culture media,
coses, Fusarium
fungal
stains.
Nonproprietary Names and Trademarks of Drugs Proparacaine-A icuira, Ophthaine, Ophthetic.
Gentamicin—Garamycin. References 1. Kaufman HE, Wood RM: Mycotic keratitis. Am J Ophthalmol 59:993-1000, 1965. 2. Wilson LA, Sexton RR: Laboratory diagnosis in fungal keratitis. Am J Ophthalmol 66:646-653, 1968. 3. Jones DB, Sexton RR, Rebell G: Mycotic keratitis in south Florida: A review of 39 cases: Trans Ophthalmol Soc UK 89:781-797,1969. 4. Jones DB, Wilson L, Sexton R, et al: Early diagnosis of mycotic keratitis. Trans Ophthalmol Soc UK 89:805-813, 1969. 5. DeVoe AG: Keratomycosis. Am J Ophthalmol 71:406-414, 1971. 6. Polack FM, Kaufman HE, Newmark E: Keratomycosis: Medical and surgical treatment. Arch Ophthalmol 85:410-416, 1971. 7. Jones DB, Forster RK, Rebell G: Fusarium solani keratitis treated with natamycin (Pimaricin). Arch Ophthalmol 88:147-154, 1972. 8. Toussoun TA, Nelson PE: A Pictorial Guide to the Identification of Fusarium Species According to the Taxonomic System of Snyder and Hansen. University Park, Penn, Pennsylvania State University Press, 1968. 9. Booth C: The Genus Fusarium. Surrey, En-
gland, Commonwealth Mycological Institute,
1971. 10. Von Arx JA: The Genera of Fungi Sporulating in Pure Culture. Lehe, Germany, Verlag von J Cramer, 1970. 11. Gams W: Cephalosporium-artige Schimmelpiltze (Hyphomycetes). Jena, East Germany, Gustav Fischer, 1971. 12. Ellis MB: Dematiaceous Hyphomycetes. Kew, England, Eastern Press, Ltd, 1971.
Downloaded From: http://archopht.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015
Management
Diagnosis
Richard K. Forster, MD, Gerbert
Rebell, MS
\s=b\ Causative isolates, clinical features, and laboratory studies are reported for sixty-one cases of culture-proved mycotic keratitis. Isolates are categorized into four groups, including 36 Fusarium solani, 11 other Moniliaceae species, seven Dematiaceae, and seven yeasts. Of the 61 patients, 42 were men. Mild outdoor trauma was sustained in 14 of 24 cases. Patients were often referred with a clinical diagnosis of presumed fungal keratitis, within one week of symptom development, and usually had not received topically applied steroids prior to referral. Laboratory diagnosis necessitates prompt corneal scrapings, preferably stained with Giemsa or Gram, and culture on Sabouraud and blood agar maintained at room temperature, with growth usually evident by 48 hours.
(Arch Ophthalmol 93:975-978, 1975)
diagnostic Clinical fungal increasing reported and istics of
character¬ keratitis have fre¬ been with quency during the last ten years.1-7 In the past five years, we have investi¬ gated 61 cases, in addition to the first 38 culture-proved cases reported from this institute.1 By providing identi¬ fication of keratitis isolates and per¬
forming sensitivity studies, we have also collected, lyophilized, and later studied fungal strains from other parts of the United States, South America, Europe, and Asia. The purpose of this report is to evaluate the specific causes, clinical features, and laboratory diagnosis of fungal keratitis in our latest 61 cases, to augment or shift the emphasis of certain impressions, and to provide a useful guide to be followed by prac¬ ticing ophthalmologists and mycologists.
SUBJECTS AND METHODS Patients
Sixty-one patients with culture-proved fungal keratitis were examined by us be¬ tween July 1969 and July 1974, on a private referral basis or from the resident service at the Bascom Palmer Eye Institute. Clini¬ cal and laboratory data from these cases were compared with 38 previously reported cases from the Bascom Palmer Eye Insti¬ tute studied prior to July 1969.3
Clinical and
Laboratory Diagnosis
All cases had culture confirmation from either corneal scrapings or keratoplasty specimens. Sabouraud agar consisted of dextrose-peptone agar with yeast extract and 50jug/ml gentamicin sulfate, without cyclohexamide, and held at room tempera¬ ture. Sheep-blood agar was inoculated and held at both room temperature (25 C) and body temperature (37 C). The liquid media consisted of brain-heart infusion (BHI) with gentamicin, 50|iig/ml, maintained on a rotary shaker (about 200 rpm) at room
temperature.
Submitted for publication July 26, 1974. From the Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami School of Medicine, Miami, Fla. Reprint requests to Department of Ophthalmology, University of Miami School of Medicine, PO Box 875, Biscayne Annex, Miami, FL 33152
(Dr. Forster).
Material from corneal scrapings was ex¬ amined by Giemsa and Gram stains, and 20% potassium hydroxide preparations. Corneal fragments obtained from surgery were examined histopathologically by Gomori methenamine silver or PAS reac¬ tions.
Isolate Identification An attempt
Downloaded From: http://archopht.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015
was
made to determine the
species of all keratitis strains us (G.R.). Fusarium species were identified according to the taxonomic guides of Snyder and Hansen5 and Booth," and some strains were personally con¬ firmed by Snyder or Nelson; other Moniliaceae were identified by the methods of Von Arx,"1 Gams," and periodical litera¬ ture; Dematiaceae species were identified by the Ellis classification,'-' and also were sent directly to Ellis for confirmation. genus and by one of
RESULTS Identification of Isolates The 61 isolates were arranged ac¬ cording to four convenient diagnostic and laboratory groups. Fusarium so¬ taní was isolated in 36 cases. Other Moniliaceae, which are nonpigmented filamentary fungi, including other species of Fusarium, accounted for 11 cases. Dematiaceae, which are pig¬ mented filamentary fungi, were iso¬ lated in seven cases. Yeasts ac¬ counted for seven isolates. If we combine the 38 cases reported by Jones1' from this institute, which cover the ten years prior to July 1969, there are a total of 99 isolates. Clinical Features
of the patients under the age of 50 years, and 28% were less than 30 years old. Of the 61 patients, 42 were men, com¬ pared to 19 women. A history of defi¬ nite local foreign-body trauma was obtained in 24 cases, and possible trauma in another five cases. The im¬ portance of outdoor or plant material (14 of 24), and frequent outdoor occu¬ pations or hobbies was evident. Octo¬ ber through April was the most fre¬ quent season of occurrence.
Fifty-seven percent
were
Steroid and Antibiotic Treatment In
only
four
cases was
there
a
his¬
tory of steroid or antibiotic use before the development of symptoms. After the development of symptoms, but
before the diagnosis of fungal kera¬ titis was confirmed, 33 patients were given antibiotics and 15 received topi¬ cal applications of steroids, including 12 with both. Definitely no antibiotics were used in 21 cases, and no steroids in 38.
Referring Diagnosis The correct
diagnosis of "suspected
fungus ulcer" was made in 19 of 33 private patients (58%). Herpes kera¬ titis was suspected in seven of 14 "missed" diagnoses. Over one half of the cases (32 of 61) were seen within one
week of symptom onset.
Appearance The clinical appearance was vari¬ but one or more of the features described by Kaufman and Wood1 were present in all cases, including slightly elevated, shaggy ulcers with hyphal stromal infiltrates surround¬ ing the ulcer, and occasionally satel¬ lite lesions, "rings," endothelial plaques, and hypopyons (Fig 1).
able,
Laboratory Corneal scrapings
with
Results
obtained after the ap¬
were
platinum spatula plication of proparacaine hydrochlo¬ ride topically, and with the aid of slit lamp microscopy. Repeated scrapings were made from the base and edges of the ulcers and were placed on Sa¬ bouraud agar, two blood agar plates, a
in brain-heart infusion broth, and placed on at least three slides to be prepared for KOH, Gram, and Giemsa stains examination. Microscopic Examinations of Scrap¬
ings.—The KOH preparation was posi¬ tive in nine cases; the Gram stain pos¬ itive in 28 cases; the Giemsa stained scraping positive in 33 cases. In 34 of the cases, all three preparations were examined. In no case was the KOH positive, with a negative Gram and Giemsa stain. Cultures.—Culture results were con¬ sidered from 69 scrapings, consisting of the 61 cases plus one culture-nega¬ tive case that had a definite positive scraping by Gram and Giemsa stains, and seven positive repeat cultures that were performed in cases initially culture positive. Of the 69 cultures, 60 were positive on Sabouraud agar; 49 were positive on liquid BHI. Since not all cases were cultured on the three media, it is probably more important to examine the media that had nega¬ tive cultures but that were positive on at least one media. There were nine negative cultures on Sabouraud agar, nine on room temperature blood agar, and 22 on BHI liquid broth. Blood agar at
body temperature (37 C)
was
positive in 36 cases and negative in 17 Most isolates grew rapidly and growth was detected by 36 to 48 hours after scrapings (Fig 2). cases.
COMMENT
Certain generalizations and de¬ scribed features of fungal keratitis may be incorrect, may need modi¬ fication, or should be stressed in order
improve the clinical-laboratory diagnosis. Our experience with 61 to
in the past five years has rein¬ forced those features that aid in more frequent recognition and causative cases
diagnosis.
Rather than consider these cases under the general diagnosis of keratomycoses, we have chosen to divide them into four major arbitrary groups of frequently encountered iso¬ lates. These consist of the following: (1) F solani; (2) other Moniliaceae; (3) Demetiaceae; and (4) yeasts. Al¬ though subtle differences in appear¬ ance and clinical features may be noted, the other differences between these groups lie in culture and mor¬
phologic characteristics, sensitivity studies to antifungal agents, and fre¬
quency of occurrence as causes of fungal keratitis. Fusarium solani was the major species of fungus in the first 38 cases reported from the Bascom Palmer Eye Institute,·1 was isolated by us in 18 consecutive cases treated with na¬
tamycin (pimaricine),7 was the causa¬ tive agent in 36 of 61 cases in this re¬ port, and accounted for about 50% of all keratitis strains sent to us for identification from other parts of the United States and South America. The second group consists of Mo¬ niliaceae other than F solani. This group may be the least homogenous and have the greatest number of spe¬ cies, but altogether, in 99 cultureproved cases in the files of the Bas¬ com Palmer Eye Institute, accounted for 15 isolates, including 11 of 61 cases in this series. The fungi in the third group are the Dematiaceae and other pigmented fungi. Curvularia, Alternaría, Drechslera, and Lasiodiplodia theobromae, which we are for convenience
including in this group, have been en¬ countered repeatedly in our collec-
Downloaded From: http://archopht.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015
1 .—Clinical appearance of F solani keratitis. Top left, Dense infiltrate with hyphal margins. Top right, Fluffy feathery borders. Bot¬ left, Nodular and satellite lesions. Bottom right, Pseudopodes and "ring" infiltrates.
Fig tom
stain. Top center, Giemsa stain. Sabouraud agar. Bottom center, Growth of F solani shaker.
Fig 2—Top left, Gram
on
Top right, Potassium hydroxide wet preparation. Bottom left, Growth of F solani on blood agar (25 C). Bottom right, Round colonies in liquid BHI from rotary
Downloaded From: http://archopht.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015
tion. The fourth group are the yeasts. These seem to occur more frequently in "sick" eyes, particularly on chronic use of steroids and antibiotics. The concept that fungal ulcers de¬ velop in older patients with debilitat¬ ing diseases or prior corneal dis¬ orders, or that most have been treated with steroids or antibiotics for indolent ulcers is not borne out by our experience. These are by and large, with the exception of the yeasts, primary infections of the cornea that are apparently intro¬ duced by minor trauma. One fourth of the patients in this series were under 30 years of age (57% under 50), and 70% were men. Cases occurred as young as 2lk and as old as 86 years. Definite trauma was experienced in 24 cases (40%), with 14 of these occurring outdoors from plant matter, dirt or stones. Although most of the patients had no prior ocular difficulties, four cases developed in patients with abnormal corneas, including three due to Can¬ dida albicans. Only two of the 61 pa¬ tients used prior topically applied steroids or antibiotics before the de¬ velopment of fungal keratitis. While the seasonal peak was in the spring and no cases developed in the months of June through September in the first series of 38 cases3; in this re¬ view of 61 cases, the onset peaked from October through April, and a to¬ tal of 13 cases developed in the months of June through September. It should be noted, however, that the peak incidence correlates with windy,
cool, and drier weather during the
months of October through April in South Florida. Awareness and a high index of sus¬ picion of fungal keratitis has ac¬ counted for a higher number of cor¬ rect referral diagnoses and the withholding of steroids following un¬ determined or outdoor trauma. Only one fourth (15 of 61) of the patients received steroids after the develop¬ ment of symptoms. This was also at¬ tested to by the prompt referral for diagnostic studies and specific antifungal management, with 33 of 61 cases initially cultured within one week of the onset of symptoms. In this study, the Giemsa and Gram stains were more reliable than the KOH preparation, and provided a permanent mount. Gomori methenamine silver or PAS histopathology of corneal fragments are sufficient for
surgical specimens. The use of multiple media will give the highest yield of positive cultures.
Sabouraud agar is probably most re¬ liable if it is available without cyclohexamide, which inhibits many of the fungi that cause keratitis. However, fresh blood agar should be considered nearly as reliable. Bacterial contami¬ nants have not been a problem, par¬ ticularly if incubated at room tem¬ perature (25 C). Usually confirmation of the presence of fungi can be made within 48 hours.
This study was supported in part by Public Health Service grant 5 ROI EY00674-2 from the National Eye Institute; Fight For Sight, Inc., grant G457; United Health Foundation of Dade
County; the Florida Lions Eye Bank; and the Flournoy and Mae Knight Clark Research Fund. Maria Suerio and Mary G. Wirta provided
technical assistance.
Key Words.—Fungal keratitis, keratomysolani, Moniliaceae fungi, Dematiaceae fungi, yeasts, culture media,
coses, Fusarium
fungal
stains.
Nonproprietary Names and Trademarks of Drugs Proparacaine-A icuira, Ophthaine, Ophthetic.
Gentamicin—Garamycin. References 1. Kaufman HE, Wood RM: Mycotic keratitis. Am J Ophthalmol 59:993-1000, 1965. 2. Wilson LA, Sexton RR: Laboratory diagnosis in fungal keratitis. Am J Ophthalmol 66:646-653, 1968. 3. Jones DB, Sexton RR, Rebell G: Mycotic keratitis in south Florida: A review of 39 cases: Trans Ophthalmol Soc UK 89:781-797,1969. 4. Jones DB, Wilson L, Sexton R, et al: Early diagnosis of mycotic keratitis. Trans Ophthalmol Soc UK 89:805-813, 1969. 5. DeVoe AG: Keratomycosis. Am J Ophthalmol 71:406-414, 1971. 6. Polack FM, Kaufman HE, Newmark E: Keratomycosis: Medical and surgical treatment. Arch Ophthalmol 85:410-416, 1971. 7. Jones DB, Forster RK, Rebell G: Fusarium solani keratitis treated with natamycin (Pimaricin). Arch Ophthalmol 88:147-154, 1972. 8. Toussoun TA, Nelson PE: A Pictorial Guide to the Identification of Fusarium Species According to the Taxonomic System of Snyder and Hansen. University Park, Penn, Pennsylvania State University Press, 1968. 9. Booth C: The Genus Fusarium. Surrey, En-
gland, Commonwealth Mycological Institute,
1971. 10. Von Arx JA: The Genera of Fungi Sporulating in Pure Culture. Lehe, Germany, Verlag von J Cramer, 1970. 11. Gams W: Cephalosporium-artige Schimmelpiltze (Hyphomycetes). Jena, East Germany, Gustav Fischer, 1971. 12. Ellis MB: Dematiaceous Hyphomycetes. Kew, England, Eastern Press, Ltd, 1971.
Downloaded From: http://archopht.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015
