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Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 253-254

Imaging for fungal kerato-uveitis


1 The Cornea Institute, Hyderabad, India
2 Jhaveri Microbiology Centre, L V Prasad Eye Institute, Hyderabad, India

Date of Submission23-May-2021
Date of Acceptance29-Jun-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Bhupesh Bagga
L V Prasad Eye Institute , Banjara Hills, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1384_21

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  Abstract 


Keywords: Anterior segment optical coherence tomography, confocal microscopy, fungal keratitis


How to cite this article:
Vishwakarma PR, Bagga B, Sharma S. Imaging for fungal kerato-uveitis. Indian J Ophthalmol Case Rep 2022;2:253-4

How to cite this URL:
Vishwakarma PR, Bagga B, Sharma S. Imaging for fungal kerato-uveitis. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:253-4. Available from: https://www.ijoreports.in/text.asp?2022/2/1/253/334873



Fungal infection presenting as deep stromal keratitis or kerato-uveitis is difficult to manage due to nonspecific clinical features or insufficient microbiological sample.[1] Noninvasive imaging techniques can be very useful in this particular entity to increase our yield of diagnosis. The present case is one such case where imaging helped to make the diagnosis of fungal kerato-uveitis.

A 42-year-old male presented to the clinic with complaints of redness and pain in the left eye for 5 days. In view of no obvious signs of infection and presence of keratic precipitates, cells, and hypopyon, he was managed as anterior iridocyclitis with corticosteroids for 7 days and worsened. At this time of presentation, there was posterior stromal corneal infiltrate measuring 5.6 × 5.2 mm extending from 3 to 6 o' clock along with filaments like structures extending into the anterior chamber [Figure 1]a and [Figure 1]b. Anterior segment optical coherence tomography (AS-OCT) confirmed the depth of involvement with hyperreflective infiltrate having feathery extensions into the anterior chamber [Figure 1]c and [Figure 2], which could be confused with inflammatory exudates or membrane, but confocal imaging showed hyperreflective linear, bifurcating branchlike filaments suggestive of fungal hyphae [Figure 1]d. Also, microscopic evaluation of aqueous sample from diagnostic anterior chamber aspiration confirmed thin branching fungal filaments [Figure 1]e. With topical natamycin 5% hourly along with oral ketoconazole 200 mg twice a day and single intracameral amphotericin B injection, there was resolution of infection in 68 days with further follow-up of 95 days without recurrence of infection.
Figure 1: (a) Left eye slit-lamp photograph showing conjunctival congestion, whitish 5.6 × 5.2 mm corneal infiltrate from 3 to 6 o' clock with feathery margins, intact epithelium, and streak hypopyon. (b) Slit-lamp photograph (optical slit): Feathery fungal hyphae extending from posterior corneal surface into the anterior chamber. (c) AS-OCT (AngioVue System, Optovue Inc., Fremont, CA – optical axial resolution of ~5 μm and transverse resolution of ~ 15 μm) Fungal filaments extending from posterior stroma into the anterior chamber. (d) Confocal microscopic image: Hyperreflective linear, bifurcating branchlike double-walled fungal filaments (red arrows). (e) KOH/CFW (potassium hydroxide/calcofluor white) stain (×40): Thin, hyaline, septate fungal filaments

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Figure 2: AS-OCT (AngioVue System, Optovue Inc., Fremont, CA – optical axial resolution of ~5 μm and transverse resolution of ~15 μm): Anterior chamber fungal filaments seen in horizontal and vertical scans

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  Discussion Top


Initial dilemma in diagnosing fungal kerato-uveitis and inadvertent treatment with corticosteroids may flare up fungal infection.[2] Fungal hyphae may have diameters of 1–30 μm and lengths ranging from a few microns to several meters.[3] This can be picked up on AS-OCT and confocal microscopy, which can help in early and in vivo diagnosis of such cases.[4],[5],[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wang SY, Zhu HF, Cheng Y, Wu J, Tian Y. Fungal corneal endotheliitis: A series of case reports. Int J Ophthalmol 2018;11:1061-5.  Back to cited text no. 1
    
2.
Cho CH, Lee SB. Clinical analysis of microbiologically proven fungal keratitis according to prior topical steroid use: A retrospective study in South Korea. BMC Ophthalmol 2019;19:207.  Back to cited text no. 2
    
3.
Islam MR, Tudryn G, Bucinell R, Schadler L, Picu RC. Morphology and mechanics of fungal mycelium. Sci Rep 2017;7:13070.  Back to cited text no. 3
    
4.
Brasnu E, Bourcier T, Dupas B, Degorge S, Rodallec T, Laroche L, et al. In vivo confocal microscopy in fungal keratitis. Br J Ophthalmol 2007;91:588-91.  Back to cited text no. 4
    
5.
Sharma N, Singhal D, Maharana PK, Agarwal T, Sinha R, Satpathy G, et al. Spectral domain anterior segment optical coherence tomography in fungal keratitis. Cornea 2018;37:1388-94.  Back to cited text no. 5
    
6.
Soliman W, Fathalla AM, El-Sebaity DM, Al-Hussaini AK. Spectral domain anterior segment optical coherence tomography in microbial keratitis. Graefes Arch Clin Exp Ophthalmol 2013;251:549-53.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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