Miscellaneous

Miscellaneous

Fungal Conjunctivitis: How

to Suspect & Diagnose Deepak Mishra
DNB, MNAMS

Deepak Mishra* DNB, MNAMS, Pratyush Ranjan* DNB, MNAMS,

Nilesh Mohan** MD, B.P. Sinha** MS

*Regional Institute of Ophthalmology, Sitapur Eye Hosptal, Sitapur

**Regional Institute of Ophthalmology, I.G.I.M.S, Patna

A lthough various fungal agents can be recovered from

the conjunctiva, fungal conjunctivitis is rarely observed
clinically. It is an uncommon disease, isolation of fungi
from normal conjunctival sac occurs in 6 to 25% of normal
individuals. There may be seasonal increase in conjunctival
fungal isolation, possibly related to airborne carriage of
candida. Rhinosporodiosis appears to be endemic in Indian
sub continent1-3.
Predisposing factors are4
1. Shared cosmetics
2. Chronic use of topical broad spectrum antibiotics
3. Prolonged use of oral or topical steroids
4. Injury from vegetative matter
5. Bathing in stagnant water
6. Immunocomprised status (HIV, Diabetes, use of
immunosuppressive drugs)
Fungal infection often appears as chronic inflammation
and scanty discharge from the eyes. On examination
conjunctival edema, hyperemia of the tarsal and bulbar
conjunctiva and granulaomata can be observed. The
discharge can be mucopurulent or frankly purulent of
yellow or green color5.
Candida conjunctivitis presents with purulent, acute or sub
acute superficial epithelial lesions, in newborns, school
children and adults with primary infection localized in
oral mucosa or vagina. A follicular papillary chronic
conjunctivitis with no response to topical antibiotics and
slow evolution is characteristic of candida conjunctivitis.
In some patients conjunctival membrane or pseudo
membrane may be obscured.

Etiology
Candida species can cause conjunctivitis after topical
corticosteroid and antibacterial therapy to an inflamed eye.
Common funguses causing conjunctivitis are candida
albicans, candida parapsilosis, candida tropicalis,
paracoccidioides brasiliensis, coccidio immitis, blastomyces
dermatitidis and rhinosporidium seeberi

Clinical Features
General features associated with fungal conjunctivitis are;
Redness, itching, discharge and irritation. The intensity of
these symptoms may depend on the type of infecting agent, Figure 1: Left showing conjunctival injection, more in
extent of the infection and immune status of the patient. medial side (the area of trauma by sugar cane leaf)

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Figure 2: Showing superficial corneal
vascularization from 7 to 11 clock position
Malassezia presents with catarrhal conjunctivitis, where as
coccidio immitis causes severe necrotizing granulomatous
conjunctivitis and or follicular conjunctivitis. Blastomyces
dermatitidis causes contiguous spread and follicular
conjunctivitis. Sporothrix schenckii presents with nodular
conjunctivitis with associated deep lesions and local
lymphadenopathy where as Aspergillus niger causes
chronic conjunctivitis with black conjunctival secretions5,6.
Immune compromised patients may experience a more
severe clinical course and demonstrate granulomatous
conjunctivitis or necrotizing conjunctivitis with sclera
melting. It may masquerade as squamous cell carcinoma,
atypical papilloma lesions or conjunctival granuloma6.
Investigations
Laboratory identification is necessary in patients presenting
with atypical granulomatous lesions. Biopsy and
histopathology is recommended diagnostic procedure.
Giemsa stain of conjunctival scrape may demonstrate
the presence of typical hyphae. Electron microscopy
can demonstrate the presence of small intracellular and
extracellular yeast organism.
Identification of the causative organism may also be
obtained either by specific culture or PCR.
For suspected rhinospororidiosis, the lesion is surgically
excised for histopathological examination. Inferior tarsal
conjunctiva and fornices are vigorously scrubbed with
calcium alginate or cotton tipped swabs. Conjunctival
biopsy specimen for histopathology & culture is indicated
if above specimen do not yield results.
Microscopic examination to identify fungus is made with
PAS, Giemsa, gram stain, Calcofluor white & Fluorescence
microscopy. Culture can be done on SDA agar
58 l DOS Times - Vol. 19, No. 9 March, 2014
Figure 3: Multiple pappilas on left upper
tarsal conjunctiva
Treatment
Medical management can be intiated with topical
amphotericin B (0.15%), natamycin (5%), fluconazole
(2%), ketonazole (2%) may be used. Generally topical
antifungal is used for superficial conjunctivitis and systemic
antifungal for deep lesions.
Necrotizing granulomatous conjunctivitis due to coccidio
immitis require aggressive debridement of the affected area
and months of topical amphotericin B & oral fluconazole
therapy.
Blastomyces dermatitidis and Sporothrix schenckii have
been associated with a granulomatous conjunctivitis.
These mycoses are treated with systemic antifungal agents,
usually itraconazole. Rhinosporidium seeberi infection of
the conjunctiva usually manifests as a fleshy, friable, red,
pedunculated mass No drug therapy has been proven
effective for rhinosporidiosis. Condition is treated by
surgical excision of the lesions. Excision of the mass with
adequate margins is often curative.
References
1. Stephen A. Klotz, Christopher C. Penn, Gerald J. Negvesky, Salim
I. Butrus. Fungal and Parasitic Infections of the Eye. Clin Microbiol
Rev. 2000; 13(4): 662–685.
2. Ando N, Takatori K. Fungal flora of the conjunctival sac. Am J
Ophthalmol. 1982;94:67–74.
3. Segal E, Romano A, Eylan E, Stein R. Fungal flora of the normal
conjuctival sac. Mykosen.1977;20:9–14.
4. W Behrens-Baumann. Developments in Ophthalmology. Vol 32.
Mycosis of the Eye and its Adnexa. Switzerland. Karger. 1999. 70 p.
5. Sehgal S, Dhawan S, Chhiber S, Sharma M, Talwar P. Frequency and
significance of fungal isolations from conjunctival sac and their role
in ocular infections. Mycopathologia. 1981;73:17–19.
6. David BenEzra. Blepharitis and Conjunctivitis. Guidelines for
Diagnosis and Treatment. 1st Edition. Israel. Editorial Glosa.2006.
104-5 p.