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 Table of Contents  
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 67-68

Triple trouble: A case report of mixed keratitis

Department of Cornea and Refractive Services, Sankara Eye Hospital, Bangalore, Karnataka, India

Date of Submission25-Aug-2022
Date of Acceptance03-Nov-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Nayana V Gowda
Sankara Eye Hospital, Kundalahalli, Bengaluru - 560 037, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2136_22

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A middle-aged female with previous history of being treated as herpes keratitis, presented with a central deep stromal ulceration and overlying neurotrophic epithelium. On re-scraping, the culture grew Pseudomonas aeruginosa and Aspergillus flavus. Due to the aggressive nature of the organisms, during follow up, a central perforation was noted, for which emergency therapeutic keratoplasty was done and post-operatively medicated with topical eye drops as per culture and sensitivity. Hence, we are presenting this rare case report of Pseudomonas aeruginosa in a non-contact lens user, along with a co-infection of Aspergillus flavus in a previously compromised cornea with herpetic keratitis.

Keywords: Corneal perforation, polymicrobial keratitis, scraping

How to cite this article:
Balasubramaniam A, Nandan BR, Gowda NV. Triple trouble: A case report of mixed keratitis. Indian J Ophthalmol Case Rep 2023;3:67-8

How to cite this URL:
Balasubramaniam A, Nandan BR, Gowda NV. Triple trouble: A case report of mixed keratitis. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:67-8. Available from: https://www.ijoreports.in/text.asp?2023/3/1/67/368211

Polymicrobial keratitis constitutes 2%–15% of infectious keratitis. Most often, they are both a diagnostic and therapeutic challenge and require a high index of suspicion from the clinician.[1] Specifically, in South India, Bharathi et al.[2] reported mixed infections to comprise 2.39% of all microbial keratitis cases. Hereby, we are reporting a case infected with Aspergillus flavus, a sporulating filamentous fungus, and co-infected with Pseudomonas aeruginosa, a gram-negative bacillus, with previous herpetic keratitis as a predisposing factor.

  Case Report Top

A 61-year-old female patient presented with complaints of pain, redness, and diminution of vision in left eye for 1 month. She had no history of trauma or systemic illness. Also, she was not a contact lens user. She had a past history of undergoing dacryocystectomy and being treated as recurrent herpetic keratitis with oral and topical acyclovir 3% for 15 years. For the above complaints, the patient had visited a local doctor, where she was treated with an antifungal as the 10% KOH mount was positive for fungal elements, but there was no improvement.

On examination, her vision was found to be hand movements, a central 5 × 5 mm deep stromal ulceration, 60% thinning of the central cornea, and overlying epithelial defect which showed some neurotrophic changes and hypopyon of 3 mm. Posterior segment was unremarkable [Figure 1].
Figure 1: Central stromal ulceration with overlying epithelial defect with neurotrophic changes

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A corneal scrape for Grams stain, KOH, and culture was obtained and the patient was empirically started on tablet acyclovir and natamycin 5% hourly. Patient reviewed 2 days later with a perforated cornea, for which a therapeutic keratoplasty was done [Figure 2]. Her corneal scraping report revealed gram-negative bacilli and fungal hyphae; culture and further speciation revealed confluent growth of P. aeruginosa and A. flavus [Figure 3]. Postoperatively, she has been using tablet acyclovir, natamycin 5%, and tobramycin 0.3% as per the sensitivity reports. She has had a successful infection-free postoperative follow-up of 1.5 months [Figure 4].
Figure 2: Central perforation with a flat anterior chamber

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Figure 3: C-streaked culture plate showing mixed growth, which was then speciated into Pseudomonas aeruginosa and Aspergillus flavus

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Figure 4: Post-therapeutic keratoplasty

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  Discussion Top

Most common organisms involved in polymicrobial keratitis include filamentous fungi and coagulase-negative staphylococci followed by Pseudomonas spp.[3],[4] P. aeruginosa keratitis in non-contact lens users tends to have a more severe course of the disease,[5] as found in our patient. Predisposing factors for mixed infections include ocular trauma (15%), preexisting ocular surface disease (9%) like herpetic keratitis, lagophthalmos, bullous keratopathy, previous ocular surgery (3%) like keratoplasty, and systemic immunosuppression.[4] Polymicrobial keratitis must be strongly suspected in patients who have had a nonhealing ulcer despite medications, treatment with over-the-counter drops, and unsupervised use of topical steroids. Another important cause of a co-infection could be the contamination of multi-dose eye drop, wherein the most common organisms involved are usually staphylococci, but Pseudomonas has also been reported.[6],[7] As a secondary analysis of mycotic ulcer treatment trial, Ray et al.[8] advocated the importance of performing a repeat scrape and found that a positive culture at 6 days has a high risk of surgical intervention, worse 3-month visual acuity, and a larger scar size. Through this case report, we want to emphasize on the importance of rescraping a nonhealing ulcer, as the possibilities of having a co-infection with another organism is high. Cases of mixed infections have been reported to be difficult to treat and have a propensity toward perforation (12%), resulting in a poorer prognosis, which is similar to that seen in our patient, who eventually required a therapeutic keratoplasty.[4]

  Conclusion Top

Mixed infectious keratitis requires a strong clinical and microbiological acumen. Although polymicrobial keratitis and challenges in treatment have been reported previously, to the best of our knowledge, this is the first case report of culture-proven combination of A. flavus and P. aeruginosa in a setting of a viral keratitis. We would like to highlight the importance of rescraping a nonhealing ulcer. These patients have a long clinical course, require frequent follow-ups, and need topical eye drops for a prolonged duration. Complications have to be anticipated and managed accordingly.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Khoo P, Cabrera-Aguas MP, Nguyen V, Lahra MM, Watson SL. Microbial keratitis in Sydney, Australia: Risk factors, patient outcomes, and seasonal variation. Graefes Arch Clin Exp Ophthalmol 2020;258:1745-55.  Back to cited text no. 1
Bharathi MJ, Ramakrishnan R, Meenakshi R, Padmavathy S, Shivakumar C, Srinivasan M. Microbial keratitis in South India: Influence of risk factors, climate, and geographical variation. Ophthalmic Epidemiol 2007;14:61-9.  Back to cited text no. 2
Fernandes M, Vira D, Dey M, Tanzin T, Kumar N, Sharma S. Comparison between polymicrobial and fungal keratitis: Clinical features, risk factors, and outcome. Am J Ophthalmol 2015;160:873-81.e2.  Back to cited text no. 3
Ahn M, Yoon KC, Ryu SK, Cho NC, You IC. Clinical aspects and prognosis of mixed microbial (bacterial and fungal) keratitis. Cornea 2011;30:409-13.  Back to cited text no. 4
Enzor R, Bowers EMR, Perzia B, Perera C, Palazzolo L, Mammen A, et al. Comparison of clinical features and treatment outcomes of pseudomonas aeruginosa keratitis in contact lens and non-contact lens wearers. Am J Ophthalmol 2021;227:1-11.  Back to cited text no. 5
Taşli H, Coşar G. Microbial contamination of eye drops. Cent Eur J Public Health 2001;9:162-4.  Back to cited text no. 6
Daehn T, Schneider A, Knobloch J, Hellwinkel OJC, Spitzer MS, Kromer R. Contamination of multi dose eyedrops in the intra and perioperative context. Sci Rep 2021;11:20364.  Back to cited text no. 7
Ray KJ, Lalitha P, Prajna NV, Rajaraman R, Krishnan T, Srinivasan M, et al. Mycotic Ulcer Treatment Trial Group. The utility of repeat culture in fungal corneal ulcer management: A secondary analysis of the MUTT-I randomized clinical trial. Am J Ophthalmol 2017;178:157-62.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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