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 Table of Contents  
COMMENTARY
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 51-52

Commentary: Fungal infections causing infectious crystalline keratopathy


1 Department of Cornea and Cataract, ICARE Eye Hospital and Postgraduate Institute, E3A, Sector 26, Noida, Gautam Buddh Nagar, Uttar Pradesh, India
2 Department of Cornea and Cataract, ICARE Eye Hospital and Postgraduate Institute, E3A, Sector 26, Noida, Gautam Buddh Nagar, Uttar Pradesh; Department of Retina, Uvea, and Cataract, ASG Eye Hospital, 149 BT Road, Kolkata, West Bengal, India

Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Uma Sridhar
Department of Cornea and Cataract, ICARE Eye Hospital and Postgraduate Institute, E3A, Sector 26, Noida - 201 301, Gautam Buddh Nagar, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2219_21

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How to cite this article:
Sridhar U, Tripathy K. Commentary: Fungal infections causing infectious crystalline keratopathy. Indian J Ophthalmol Case Rep 2022;2:51-2

How to cite this URL:
Sridhar U, Tripathy K. Commentary: Fungal infections causing infectious crystalline keratopathy. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 19];2:51-2. Available from: https://www.ijoreports.in/text.asp?2022/2/1/51/334933



In a case report[1] in the Indian Journal of Ophthalmology, the authors have reported a case of infectious crystalline keratopathy (ICK) developing after mucous membrane grafting in a case of Stevens–Johnson syndrome (SJS).

Since Gorovoy and colleagues reported ICK as “intrastromal noninflammatory bacterial colonization of a corneal graft,” many etiological agents have been detected. Streptococcus viridans (alpha-hemolytic Streptococcus) is the most common organism causing ICK.

Other reported bacterial causes of ICK include (co-infection may be present)[2] Staphylococcus epidermidis and other coagulase-negative Staphylococci including S. haemolyticus, Staphylococcus aureus, Streptococcus pneumoniae, S. mitis, S. sanguinis, S. anginosus, S. oralis, S. parasanguinis, S. pyogenes, Gemella haemolysins, Actinomyces, Peptostreptococcus, Abiotrophia defectiva, A. adiacens, Klebsiella oxytoca, Enterococcus faecalis, Haemophilus aphrophilus, H. influenza, Pseudomonas aeruginosa, P. fluorescens, Stenotrophomonas maltophilia, Enterobacter aerogenes, Citrobacter koseri, Achromobacter, Acinetobacter calcoaceticus, Propionibacterium acnes, Serratia marcescens, S. liquefaciens, Corynebacterium, Aerobic diphtheroids, Mycobacterium abscessus, and M. chelonae.

Protozoa associated with ICK include Acanthamoeba; however, most cases had mixed infection with another organism known to cause ICK.

However, various fungi have also been implicated in ICK. Such fungi include Candida tropicalis, C. albicans, C. parapsilosis (after PK/penetrating keratoplasty, coinfection with Staphylococcus aureus after phacoemulsification, after DSAEK), C. guilliermondii, Fusarium solani (after corneal collagen crosslinking),[2] Alternaria (after LASIK), Microsporidium (reclassified as fungus from protozoa),[3] and Cladosporium sphaerospermum.

Usual features of ICK include crystalline or needle-like deposits at anterior or mid-corneal stroma, absence of inflammation, and local (topical steroids) or systemic immunocompromise. The organism is thought to enter the corneal stroma via epithelial defect or epithelial ingrowth. The biofilm around the organism may reduce the penetration of antimicrobial causing a challenge to successful medical therapy. The routine corneal scraping may not yield the microorganism as it is sequestered in between the corneal stroma. Corneal biopsy may be needed. Candida albicans may be associated with biofilm made of polysaccharide-rich glycocalyx on electron microscopy.

Weisenthal and colleagues[4] reported 2 elderly females who developed ICK after PK due to Alternaria and Candida tropicalis, respectively.

In this case report,[1] the organism was successfully detected by microbiological workup, and a sensitivity profile was also done, which is not so commonly performed for antifungal agents as a routine. As a result, the outcome was a successful resolution of the infection.

SJS and toxic epidermal necrolysis are the extreme ends of the spectrum of drug reactions. The devastating effect of SJS on the ocular surface is well known. Severe dryness and keratinized/dermalized ocular surface in untreated cases lead to irreparable loss of vision. Lid margin keratinization has a sandpaper effect on the cornea and leads to pannus formation, scarring, and keratinization. Use of amniotic membrane graft in corneal involvement in acute stage of SJS has been described.[5] Mucous membrane grafting whether from the upper or lower lip or buccal mucosa helps to prevent/reduce lid margin keratinization and increases patient comfort.

Sharma and colleagues[6] described 83 eyes with microbial keratitis of 68 patients with SJS. Bacterial infection was noted in 62.5% of cases with positive culture reports, positive fungal culture was noted in 8.3%, and polymicrobial infection was noted in around 30% of cases.[6] No cases with ICK were described. Compromised ocular surface and the lowered immunity of these patients make them vulnerable to infectious keratitis which must be prevented or diagnosed and treated early.

ICK has been reported in SJS to be caused by Mycobacterium abscessus, which also caused endophthalmitis,[7] and Candida albicans.[8] This present case[1] adds to the literature that Candida parapsilosis is another agent that can cause ICK in SJS.



 
  References Top

1.
Mishra P, Mishra SK, Sati A, Kumar SV, Kumar P, Chauhan R. An unusual case of Candida parapsilosis causing infectious crystalline keratopathy in Steven–Johnson syndrome. Indian J Ophthalmol Case Rep 2022;70:49-51.  Back to cited text no. 1
    
2.
Porter AJ, Lee GA, Jun AS. Infectious crystalline keratopathy. Surv Ophthalmol 2018;63:480-99.  Back to cited text no. 2
    
3.
Sridhar U, Rahman AA, Batra J, Sapra N. Ocular microsporidiosis—Our experience in a tertiary care centre in North India. Open J Ophthalmol 2015;05:130-8.  Back to cited text no. 3
    
4.
Weisenthal RW, Krachmer JH, Folberg R, Dunn SP, Whitson WE. Postkeratoplasty crystalline deposits mimicking bacterial infectious crystalline keratopathy. Am J Ophthalmol 1988;105:70-4.  Back to cited text no. 4
    
5.
Sridhar U, Tripathy K. Amniotic Membrane Graft. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.  Back to cited text no. 5
    
6.
Sharma N, Venugopal R, Singhal D, Maharana PK, Sangwan S, Satpathy G. Microbial keratitis in Stevens-Johnson syndrome: A prospective study. Cornea 2019;38:938-42.  Back to cited text no. 6
    
7.
Uy HS, Nguyen QD, Durand ML, Paton B, Foster CS. Infectious crystalline keratopathy and endophthalmitis secondary to Mycobacterium abscessus in a monocular patient with Stevens-Johnson syndrome. Am J Ophthalmol 1999;127:209-10.  Back to cited text no. 7
    
8.
Elder MJ, Matheson M, Stapleton F, Dart JK. Biofilm formation in infectious crystalline keratopathy due to Candida albicans. Cornea 1996;15:301-4.  Back to cited text no. 8
    




 

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