Int Ophthalmol
DOI 10.1007/s10792-014-9951-7
ORIGINAL PAPER
Clinical and epidemiological characteristics of infectious
keratitis in Paraguay
Martin M. Nentwich • M. Bordón • D. Sánchez di Martino • A. Ruiz Campuzano
W. Martı́nez Torres • F. Laspina • S. Lichi • M. Samudio • N. Farina •
Rosa R. Sanabria • Herminia Mino de Kaspar
Received: 12 May 2013 / Accepted: 17 April 2014
Ó Springer Science+Business Media Dordrecht 2014
Abstract To describe the clinical and epidemiolog-
ical characteristics of patients with severe infectious
keratitis in Asunción, Paraguay between April 2009
and September 2011. All patients with the clinical
diagnosis of severe keratitis (ulcer C2 mm in size and/
or central location) were included. Empiric treatment
consisted of topical antibiotics and antimycotics; in
cases of advanced keratitis, fortified antibiotics were
used. After microbiological analysis, treatment was
changed if indicated. In total 48 patients (62.5 %
males, 25 % farmers) were included in the analysis. A
central ulcer was found in 81.3 % (n = 39). The
median delay between onset of symptoms and time of
first presentation at our institution was 7 days (range
1–30 days). Fungal keratitis was diagnosed in 64.5 %
(n = 31) of patients, of which Fusarium sp. (n = 17)
was the most common. Twenty-one patients (43.8 %)
Presented in part at the Annual Meeting of the Association for
Research in Vision and Ophthalmology (ARVO), May 2012,
Fort Lauderdale, USA.
M. M. Nentwich (&)
H. M. de Kaspar
Department of Ophthalmology, Ludwig-Maximilians-
University, Mathildenstr. 8, 80336 Munich, Germany
e-mail: martin.nentwich@med.uni-muenchen.de
M. Bordón
D. S. di Martino
A. R. Campuzano

W. M. Torres
F. Laspina
S. Lichi
M. Samudio

N. Farina
R. R. Sanabria
Fundación Banco de Ojos ‘‘Fernando Oca del Valle’’,
Instituto de Investigaciones en Ciencias de la Salud,
Asunción, Paraguay
•
reported previous trauma to the eye. The globe could
be preserved in all cases. While topical therapy only
was sufficient in most patients, a conjunctival flap was
necessary in six patients suffering from fungal kera-
titis. The high rate of fungal keratitis in this series is
remarkable, and microbiological analysis provided
valuable information for the appropriate treatment. In
this setting, one has to be highly suspicious of fungal
causes of infectious keratitis.
Keywords Antibiotics
Epidemiology

Infectious keratitis
Fungal keratitis
Introduction
Severe infectious keratitis is a serious, potentially
sight-threatening condition, which requires prompt
treatment. Corneal opacities still represent important
causes of global visual impairment (1 % of all visually
impaired people worldwide) and blindness (4 % of all
blind people worldwide) [1]. Corneal ulceration may
even be responsible for 1.5–2.0 million new cases of
monocular blindness annually [2].
The distribution of microorganisms responsible for
infectious keratitis varies depending on the geographic
region. A recent review article found the highest
proportion of bacterial corneal ulcers in studies from
North America, Australia, the Netherlands, and Sin-
gapore, while the highest proportions of fungal
infections were seen in studies from India and Nepal
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[3]. Risk factors for infectious keratitis include
systemic factors such as diabetes mellitus, local
factors like lid/skin abnormalities, blepharitis, and
external factors such as trauma due to contact lens
wear [3, 4].
Results of microbiological cultures are essential for
the appropriate antibiotic treatment of infectious
keratitis [5]. However, as these results are not
available at the time of first presentation of patients,
empirical treatment based on the clinical aspect of the
lesion and on epidemiological data for the specific
region is necessary until culture results are available.
Especially in cases of severe infectious keratitis with
progressed disease and a large, centrally located
infiltrate, the use of potent topical antibiotics is
important in order to control active infection as early
as possible.
In this work, we aim to describe the clinical and
epidemiological characteristics of patients with severe
infectious keratitis at Fundación Banco de Ojos Eye
Hospital, a non-profit ophthalmic center in Asunción,
Paraguay between April 2009 and September 2011.
Materials and methods
After approval of the Institutional Review Board of our
institution had been obtained, all patients with the clinical
diagnosis of severe keratitis (inclusion criteria: ulcer
C2 mm in size and/or central location) were included in
this study. Demographic and clinical data, as well as
treatment, clinical outcome, and risk factors were
retrospectively analyzed. Empiric treatment consisted
of topical antibiotics (moxifloxacin 5 mg/ml) and an-
timycotics (fluconazole 2 mg/ml); in cases of advanced
keratitis, fortified antibiotics were used (cefazolin
50 mg/ml or vancomycin 50 mg/ml ? gentamicin).
After topical anesthetics had been applied corneal
scraping was performed in all patients to obtain
material for microbiological culture. The specimens
were inoculated onto blood-, chocolate-, and Sabou-
raud agar and in thioglycolate broth. Blood and
chocolate agar culture media were incubated for 5 to
7 days at 37 °C, while Sabouraud agar was incubated
at 28 °C for 10 days in a humidified incubator [6]. All
media were controlled for bacterial and fungal growth
on a daily basis and in case of growth, the microor-
ganisms were identified by a microbiologist.
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Depending on the results of the microbiological
analysis, empirical treatment was changed if indi-
cated. In case of fungal keratitis, patients received
topical treatment every hour either natamycin 5 % or
fluconazole 0.2 % and moxifloxacin six times a day. In
case of bacterial keratitis, topical moxifloxacin was
used. Cefazolin or vancomycin was chosen in cases
with very large infiltrates for gram-positive bacteria,
while gentamicin was used for gram-negative bacteria
and ceftazidime in case of Pseudomonas aeruginosa.
In every case, treatment was applied every hour until
ten o’clock in the evening or even throughout the night
during the first day of treatment.
Results
In total 48 patients were included in the analysis.
There were 30 male (62.5 %) and 18 female (37.5 %)
patients. The age- distribution of patients is shown in
Fig. 1. Twenty-five percent of patients (12/48) were
farmers which represent a population at the increased
risk for fungal keratitis. Previous trauma was reported
by 21 patients (43.8 %) (16 males; 5 females). Organic
material was involved in 14 of these patients. The
median delay between the onset of symptoms and the
time of first presentation at our institution was 7 days
(range 1–30 days). Some kind of topical treatment had
already been started in 18 patients before they
presented at our institution (antibiotics n = 8; antibi-
otics ? antifungal treatment n = 1; antibiotics/ste-
roid combination n = 7; cortisone n = 1; and
traditional medication n = 1).
In 89.6 % (n = 43) of cases, patients complained
of a painful eye, while pain was absent in 5 patients
(10.4 %). A central location of the ulcer was found in
81.3 % (n = 39). Mean visual acuity at presentation
was 0.025 (no difference between fungal and bacterial
keratitis). Hypopyon was present in 41.7 % (20/48) of
patients (18/31 fungal keratitis cases and 2/12 bacte-
rial keratitis cases; p = 0.019).
Fungal keratitis was diagnosed in 64.5 % (n = 31)
of patients (22 males; 9 females), of which Fusarium
sp. (n = 17) Aspergillus sp., Acremonium sp., and
Curvularia sp. were the most common (Figs. 2, 3, 4).
Bacteria were identified in 22.9 % (11/48) of patients,
while there was no growth in five patients (rate of
positive cultures 89.6 %) (Table 1). With regard to the
microbiological results of the 12 farmers, we noted
Int Ophthalmol

Fig. 1 Age distribution of

patients

Fig. 2 Direct microscopy

of scraping specimen: fungi
filaments of Aspergillus sp.

Fig. 3 Culture from

Acremonium sp. onto
Sabouraud and Blood agar

fungal growth in 66.7 % (8/12), growth of enterococci
in 16.7 % (2/12) and no growth in two cases. In the
cultures of the 14 patients who reported trauma by
organic material, fungal growth was seen in 78.5 %
(11/14) and enterococci were identified in 14.3 % (2/
14) while one culture remained sterile.
After the results of the microbiological cultures had
been obtained, empirical antibiotic therapy as
described in the methods section was changed in
50 % (24/48) of patients.
The globe could be preserved in all cases. Topical
therapy only was sufficient in most patients. However,

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Fig. 4 Acremonium sp. keratitis: a Day 1 b Day 2 c Day 4 d Culture result

Table 1 Identified Microorganisms Discussion

Fungi 31
Fusarium sp. 17 Severe infectious keratitis is an important cause of
Aspergillus sp. 5 monocular blindness, especially in developing coun-
Acremonium sp. 3 tries [2]. In the present study, about two-thirds of
Curvularia sp. 3 patients were male and one out of four patients was a
Others 3 farmer, which is in accordance to previously published
Bacteria 11 data from the same region acquired in the 1990s [6].
Streptococcus pneumoniae 1 Male patients were especially affected in the working-
Staphylococcus aureus 1 age group 20–59 years-of-age, with regard to fungal
Pseudomonas aeruginosa 2 infection (male: female ratio = 22:9) and trauma
Propionicbacterium acnes 1 (male: female ratio = 16:5).
Moraxella sp. 1 As topical eye medication is readily available over-
Klebsiella pneumoniae 1 the-counter in Paraguay, 37.5 % (18/48) of patients
Enterococcus sp. 4 reported self-medication before seeking professional
No growth 5 help by an ophthalmologist. The most commonly used
topical medications were antibiotics or a combination
of antibiotic/steroid eye drops. These results are
similar to the findings of the previously cited study
a conjunctival flap was necessary in 6 patients from the 1990s in Paraguay [6].
suffering from fungal keratitis to promote healing In the present study, the rate of positive cultures
and one of these patients underwent penetrating was 89.6 % even though almost 40 % of patients had
keratoplasty after the infection had been controlled. been using topical antibiotics at the time when the
Mean visual acuity after treatment of infectious specimen was acquired. This may be due to the
keratitis was 0.063 at last follow-up with similar standardized microbiological work-up of the speci-
results for fungal and bacterial keratitis. mens and the use of different culture media. This rate

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of positive cultures is on the high end compared to
similar studies, where microbiological cultures were
positive in 35–86 % of cases [3, 4, 7, 8].
The high rate of 64.5 % of patients suffering from
fungal keratitis which was found in microbiological
culture is remarkable but comparable to a study in
Paraguay from the late 1980s. Here 26/45 (58 %) of
cases of infectious keratitis were caused by filamen-
tous fungi [9]. This high number is comparable to
studies from India, while northern countries report a
lower incidence-rate [3, 8, 10, 11]. The great propor-
tion of fungal keratitis in the present series may well
be influenced by the high percentage of farmers in this
study and the climate in the region.
Microbiological analysis of the specimen provided
valuable information for the appropriate antifungal
treatment in these patients and resulted in a change of
antibiotic/antifungal therapy in 50 % of patients.
There are clinical signs which help to distinguish
between bacterial and fungal keratitis such as the
presence of an irregular/feathery border, which was
associated with fungal keratitis, or an epithelial
plaque, which was associated with bacterial keratitis
in a recently published study [12]. Additionally,
patients’ history, such as previous trauma or contact
lens wear, gives important information on the type of
microorganism and helps to choose empirical antibi-
otic/antifungal therapy. In the present series, hypo-
pyon was more often present in fungal keratitis
compared to bacterial keratitis cases. However, in a
recent study, corneal specialists were able to distin-
guish between fungal and bacterial etiology of infec-
tive keratitis in 66 % of patients only, based on these
clinical signs, which supports the importance of an
appropriate microbiological work-up of specimens
obtained from affected patients [12].
In the present study, 54.2 % (26/48) of patients
presented within 7 days after onset of symptoms,
while presentation of 13 patients was delayed by
15 days or more. So, the rate of patients who presented
within one week after onset of symptoms is more than
twice the one seen in Paraguay in the 1990s and higher
than in a study from India, in which 44 % of patients
presented within seven days after onset of symptoms
[6, 13]. Therefore, one might postulate that awareness
to seek appropriate ophthalmologic treatment in cases
of eye-pain or ocular trauma has increased during the
last 10 years in Paraguay. Self-medication, on the
other hand, and even the use of topical corticosteroid
eye drops is still performed by a high percentage of
patients.
With intensive treatment and regular controls active
infection could be controlled and an increase of visual
acuity could be achieved in most patients. However,
central scars may persist and keratoplasty may be
necessary to improve the visual outcome in these
patients.
There are several limitations to this study. Due to its
retrospective design, only patients who actually came
to Fundación Banco de Ojo for treatment were
included in the study. Therefore, no data on actual
incidence of infectious keratitis could be gathered, as
patients with less-severe infection might not have
sought medical help. As the number of patients with
severe infectious keratitis, who met the inclusion
criteria, was limited, the optimal antibiotic/antifungal
treatment for each causative organism cannot be
judged on the basis of this data.
However, the results of this study show that at
Fundación Banco de Ojos Eye Hospital, Asunción,
Paraguay, one has to be highly suspicious of fungal
keratitis in patients presenting with infectious kerati-
tis. Therefore, we recommend in our setting, the
empirical use of antifungal medication in cases of
trauma with organic material and farmers in all cases
until microbiological results are available.
Acknowledgments Conflict of interest None of the authors
has any conflict of interest with the submission.
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