Journal review fungal keratitis


Overview (keratomycosis/mycotic keratitis)
   

  

First described by LEBER in 1879. Quite common in tropics,agrarian countries and warmer climates. Seasonal variation(INDIA-sep,oct) May be a part of normal external ocular flora(aspergillus,rhodotorula,candida,penicillium.clad osporium,alte-rnaria species) Incidence of fungal keratitis varies according to geographical location(SOUTHERN INDIA) Internationally Aspergillus species is the most common isolate in fungal keratitis worldwide. In India ,Aspergillusspecies is the most common isolate (27-64%), Fusarium (6-32%) and Penicillium (2-29%) species (overall,incidence 6-20%,india)








Etiological factors
Trauma (outdoors,agriculture,foreign body)  Ocular surface disorders

 Topical

drugs abuse  Immunosuppression  Contact lens wearers  Corneal surgeries

JOURNAL OF CORNEA , 2009 Jul ; 28 ( 6 ): 638 - 43 . Fungal keratitis : changing pathogens and risk factors .
Jurkunas U, Behlau I, Colby K PURPOSE : To describe changes in demographics and pathogens for fungal keratitis cases diagnosed at the Massachusetts Eye and Ear Infirmary .
METHODS: Patient demographics , clinical and laboratory findings , treatment and outcomes of 46 cases of culture-proven fungal keratitis diagnosed from January 2004 through November 2007 were compared with 23 cases of fungal keratitis previously collected over a similar period from January 1999 through November 2002. RESULTS : During 2004-2007, the rate of fungal keratitis was 1.0 cases per month, an increase from the baseline rate of 0.5 cases per month during 1999-2002. The proportion of cases caused by filamentous fungi increased from 30% (1999-2002) to 65% (2004-2007) (P = 0.01). Soft contact lens wear accounted for 41% of fungal keratitis cases in 2004-2007, as compared with 17% in 1999-2002. The majority of patients (70%) received oral antifungal treatment in addition to topical amphotericin B and natamycin. Seventeen patients (40%) required therapeutic keratoplasty. Patients with a history of corneal transplant had the highest rate of therapeutic keratoplasties (67%) and had the poorest visual outcome (40% counting fingers or less). In the contact lens group, 94% of patients maintained vision of at least 20/40 and only 12% required surgery to control the infection.

CONCLUSIONS : There has been an increase in fungal keratitis in the
Boston area factors for majority of predominant

and a change in the causative pathogens and risk infection . Filamentous fungi now account for the fungal keratitis cases , whereas yeasts were the pathogen in the past . Soft contact lens wear is

JOURNAL OF CORNEA : April 2008 - Volume 27 - Issue 3 - pp 283 - 287 Predisposing Factors and Etiologic Diagnosis of Ulcerative
Keratitis Sirikul, Tasanee , Prabriputaloong, Tisha ; Smathivat, Achavee;Chuck, Roy S , Vongthongsri, Anun Purpose : To determine the predisposing factors , demographic characteristics , and etiology of ulcerative keratitis in a referral center in Bangkok , Thailand .

Methods: The medical records of admitted patients with positive-culture ulcerative

keratitis were retrospectively reviewed for demographic data, predisposing factors, and microbial culture results. Predisposing factors were compared between bacterial and fungal keratitis.Results : From January 2001 to December 2004, there were 127 positiveculture ulcerative keratitis cases. The most frequent microbiological diagnosis was bacterial keratitis (76 eyes, 60%), followed by fungal (48 eyes, 38%) and Acanthamoeba keratitis (3 eyes, 2%). The most common organisms isolated were Pseudomonas spp. for bacteria and Fusarium spp. For fungus. Compared with bacterial keratitis, fungal keratitis was more likely to be associated with ocular trauma (odds ratio = 11.20; 95% confidence interval, 3.62-34.66) but less likely to be associated with contact lens wear (odds ratio = 0.02; 95% confidence interval, 0.01-0.08).

Conclusions :

In our study , Pseudomonas and Fusarium species are the most common causes of bacterial and fungal keratitis , respectively . Fungal keratitis was more likely than bacterial keratitis to be associated with ocular trauma ,

Journal of Ocular Pharmacology and Therapeutics , June 2009 , 25 ( 3 )

Association Between Moxifloxacin Ophthalmic Solution and Fungal Infection in Patients With Corneal Ulcers and Microbial Keratitis . This study investigated Robert J. Mack, Susan Shott, Scott Schatz,present whether fungal contamination was Sean J. Farley. in bottles of a widely used moxifloxacin ophthalmic solution , and whether there was an association between the use of this solution and fungal keratitis in a corneal referral practice .
Methods: Fungal cultures were obtained for 32 moxifloxacin bottles brought in by 32 keratitis patients referred to our cornea practice from June 2003 to March 2006.Demographic and clinical data were also collected for 29 patients with fungal keratitis and 82 patients with bacterial keratitis, referred to our practice for corneal ulcers between June 2003 and April 2006. These two groups were compared with respect to moxifloxacin use and other variables.Logistic regression was carried out to determine whether an association between fungal keratitis and moxifloxacin use was present after taking into account potential confounding grew fungus on culture. Patients withthe bottles of moxifloxacin solution as likely as variables . Results:Thirteen(41%) of fungal keratitis were nearly twice patients with bacterial keratitis to report the use of moxifloxacin ophthalmic solution: 41% vs. 22% (P = 0.043). The association between fungal keratitis and moxifloxacin use persisted after taking into account potential confounding variables.

Conclusions : Fungal contamination is present in the moxifloxacin bottles used by some keratitis patients . There appears to be an association between the use of moxifloxacin ophthalmic

International Journal of Infectious Diseases , 2009 , Volume 13 , Issue 4 , Pages 443 - 448
S. Ma, K. So, P. Chung, H. Tsang, S. Chuang Starting in mid-2005, an increase in fungal keratitis caused by Fusarium spp was observed among contact lens wearers in Hong Kong, Singapore, and the USA. The objective of this study was to describe the outbreak and to determine any association with the use of Bausch & Lomb ( B & L ) ReNu® contact lens solution.
Methods:We defined a case as a disposable contact lens user with ophthalmologist diagnosed keratitis and a positive culture of Fusarium spp reported to the Department of Health from January 1, 2005 to May 31, 2006. We identified cases through inpatient discharge data and the electronic laboratory databases of all public hospitals, and from physician reporting. Controls were recruited from three outpatient clinics. Risk factors were collected using a standardized questionnaire and analyzed by univariate analysis and binary logisticregression.Results:From January 2005 through May 2006, we identified 33 cases of Fusarium keratitis. Most were in young adults (mean age 28 years) who presented with eye pain (100%), redness (84%), photophobia (41%), and tearing (34%). Twenty-four cases and 86 controls were recruited in the case–control study. By logistic regression, B&L ReNu solution showed the strongest association with being a case (adjusted odds ratio 26.1,95% confidence interval 3.0–225.3) after adjusting for potential confounders.


Using B & L ReNu contact lens solution was strongly associated with Fusarium keratitis among disposable contact lens users in Hong Kong . B & L ReNu with MoistureLoc® was permanently withdrawn from the market globally in May 2006 .

JOURNAL OF CORNEA , JAN 2009 , VOL . 28 , ISSUE 1 , pg 105 - 7 Unilateral candida parapsilosis interface keratitis after laser assisted In situ keratomileusis : case report and review of the literature .
Chen WL,TsaiYY, Lin JM,Chiang CC

PURPOSE: To describe a rare case of early-onset Candida parapsilosis infection after laser in situ keratomileusis (LASIK) and review the published reports of post-LASIK fungal infections
METHODS : A 32-year-old woman presented with interface infiltration in the central interface in the right eye 2 days after LASIK surgery. The right eye flap was lifted, and the opacities were scraped. Two days later, a 3- x 3-mm-dense oval opacity and diffuse hazes were noted. Surgical intervention was arranged because of suspicion of interface infectious keratitis. RESULTS: After an apparent post-LASIK keratitis with related interface inflammation failed to respond to medical therapy, corneal culture results were positive for C. parapsilosis 2 weeks 6 days after presentation. The patient was started on topical drops of amphotericin B 0.15% every hour after the smear showed the presence of yeast. The opacities decreased, and the topical antifungal drops were tapered. One month later, her uncorrected visual acuity recovered to 20/20.


Candida parapsilosis interface keratitis after LASIK may occur in the early phase. Early diagnosis and proper treatment can result in good outcome.

Dry, coarse,tough ,hyphate branching ulcers.  Yellowish white infiltrates, raised creamy or dirty grey surface with irregular feathery edges.  Satellite lesions  Wessley’s ring  Endothelial plaques  Hypopyon  Mild iritis

How to diagnose ??
 Clinical

picture  Microbiological investigations  Histopathology(corneal biopsy)  Immunofluoroscent staining  AC tap/paracentesis  Vitreous tap  Confocal microscopy  Electron microscopy  PCR

STAINS Gram’s Giemsa Gomori’s methenamine silver KOH(10%) PAS Acridine orange

features Stains walls of fungi Blue/ purple Black against lgtgreen background Fungal hyphae in a very light yellow colour fungi Yellow/red orange against green background Clear haloes against dark background More intense blue against a lgt blue bkground Green fluorescing structures(fungi,acanth)

COMMENT Yeasts,bact,acanth Yeast ,fungal hyphae,bact,acanth,chla-mydia Expensive Difficult technique 80-90%sensitive

fluorescent microscope Bact,acanth,yeasts cryptococcus

India ink Lactophenol cotton blue

Calcofluor white

Fluorescent microscope Costly Trained personnels

Gram stain showing aspergillus sp

Culture media
agar(fungi,aerobic bacteria)  Saboraud dextrose agar  Brain heart infusion agar  Thioglycollate broth NOTE:Cultures should be sent frmtopically applied medications,contact lenses and their solutions.
 Blood

The Internet Journal of Ophthalmology and Visual Science. 2009 Vol.6,NO.2
V. K. Sharma, M. Purohit & S. Vaidya Purpose : To know the incidence of mycotic keratitis among the all corneal blindness cases along with predisposing factors .
Material and Methods: We have included in the present study 201 consecutive cases of corneal ulcer attended hospital during April 2006 to November 2007. Diagnosis of mycotic keratitis was confirmed by history, clinical examination, direct microscopic examination of corneal scraping from the edge of ulcer for fungal hyphae and culture of fungus of corneal scraping and pus from anterior chamber, in different culture medias. Results : 42 cases (20.9%) of fungal corneal ulcer were found to be positive by direct examination and / or by culture. Fungal hyphae were seen by wet mount KOH preparation in 34 (80.9%) and culture growth present in 37 (88.0%) cases. Patients who have both test positive were 31(73.8%). Out of 34 culture grown 23 (54.7%) had pure fungal growth while 14(45.3%) showed fungus with superadded bacterial infections. Aspergillus fumigatus was the commonest causal agent isolated from 12 cases (5.9%) followed by in order to frequency are Aspergillus flavus (3.9 %), Candida (4.48 %), Curvularia (2.98 %), Penicillium (2.49 %) and Fusarium species (1.0 %).

Epidemiological study of Mycotic Keratitis

Conclusion : This study suggests that in all cases of corneal ulcer , corneal scraping is mandatory for early diagnosis of mycotic keratitis to prevent corneal blindness as there is a high incidence ( 20 . 9 %) particularly in tropical agricultural regions.

JOURNAL OF CORNEA , 2009 , JAN , VOL . 28 , ISSUE 1 : 11 - 3
Das S, Samant M, Garg P, Vaddavalli PK, Vemuganti GK.

PURPOSE : The purpose of this study was to assess the

role of in vivo confocal microscopy in cases of fungal keratitis presenting with a deep stromal infiltrate .
METHODS: We reviewed the medical , microbiologic , and histopathologic data of 6 patients , whose clinical presentation was characterized by deep stromal or multifocal endothelial lesions. These patients were subjected to in vivo confocal microscopy on the day of presentation. All the patients underwent therapeutic penetrating keratoplasty. The excised corneal buttons were bisected and subjected to microbiologic and histopathologic examinations. RESULTS : Microbiologic and/or histopathologic examination proved that the keratitis in all the 6 patients was caused by filamentous fungi. Five corneal buttons were positive for the fungus on histopathologic examination. Four specimens grew out fungus on microbiologic examination. In 5 (83%) cases, confocal microscopy revealed double-walled, septate, linear branching structures resembling fungal filaments.

CONCLUSIONS : In vivo confocal microscopy can be a useful diagnostic tool in patients presenting with deep stromal lesions .

     

Medical Antifungals Antibiotics Cycloplegics Antiglaucoma drugs NSAID’S

 

 

 

Surgical Superficial keratectomy/debri deme-nt Conjunctival flap(vasculoplasty) Intracameral amphotericin –B inj Intracorneal amphotericin-B inj. Keratoplasty

Agent POLYENES Amphotericin B Natamycin IMIDAZOLES Clotrimazole Ketoconazole Miconazole TRIAZOLES Fluconazole Itraconazole PYRIMIDINES Flucytosine Route Topical,s/c,intracam suspension topical Topical,oral Suspension,s/c Topical,oral Topical,oral Topical,,oral Concentration 0.15%,0.5-1mg,7.5-10ug in 0.1 ml 5% 1% 5%,300mg/day 1%,5-10mg 0.2%,200mg/day 1%,100-200mg/day 2%,50-150mg/kg/day(BD)

Improved ulcer after antifungals

Gopinathan U, Sharma S, Garg P, Rao GN


PURPOSE: To review the epidemiological characteristics, microbiological

profile, and treatment outcome of patients with suspected microbial keratitis.
MATERIALS AND METHODS: Retrospective analysis of a non-comparative series from the database was done. All the patients presenting with corneal stromal infiltrate underwent standard microbiologic evaluation of their corneal scrapings, and smear and culture-guided antimicrobial therapy. RESULTS : Outof 5897 suspected cases of microbial keratitis,3563 (60.4%) were culture -proven (bacterial --1849, 51.9%; fungal --1360, 38.2%; Acanthamoeba --86, 2.4%; mixed -268, 7.5%). Patients with agriculture-based activities were at 1.33 times (CI 1.16-1.51) greater risk of developing microbial keratitis and patients with ocular trauma were 5.33 times (CI 6.41-6.44) more likely to develop microbial keratitis. Potassium hydroxide with calcofluor white was most sensitive for detecting fungi (90.6%) and Acanthamoeba (84.0%) in corneal scrapings, however, Gram stain had a low sensitivity of 56.6% in detection of bacteria. Majority of the bacterial infections were caused by Staphylococcus epidermidis (42.3%) and Fusarium species (36.6%) was the leading cause of fungal infections. A significantly larger number of patients (691/1360, 50.8%) with fungal keratitis required surgical intervention compared to bacterial (799/1849, 43.2%) and Acanthamoeba (15/86, 17.4%) keratitis. Corneal healed scar was achieved in 75.5%, 64.8%, and 90.0% of patients with bacterial, fungal, and Acanthamoeba keratitis respectively.


While diagnostic and treatment modalities are well in place the final outcome is suboptimal in fungal keratitis . With more effective treatment available for bacterial and Acanthamoeba keratitis , the treatment of fungal keratitis is

Ann Pharmacother . 2009 Dec ; 43 ( 12 ): 2103 - 7 . Epub 2009 Oct 27 . Successful use of topical voriconazole 1 % alone as first - line antifungal therapy against Candida albicans keratitis . D, Leung L, Davies GE, Stewart K, Kong D. Badriyeh
OBJECTIVE: To report the successful use of topical voriconazole 1 % given alone as primary therapy against a case of Candida albicans keratitis .

CASE SUMMARY: A 48-year-old previously well man presented to the emergency department with pain and foreign body sensation in the left eye following exposure to dust while driving a forklift. He wore weekly disposable soft contact lenses. Anterior stromal scar and dense infiltrate were detected in the left eye. The anterior chamber remained deep, with flare and copious white cells. Intraocular pressure was 12 mm Hg and visual acuity was 20/200. The epithelial defect persisted, with progressive thinning despite topical fluorometholone and ofloxacin 0.3% therapy for 2 days. Microbiology testing revealed C. albicans as the affecting pathogen. Hourly administration of voriconazole 1% eye drops was initiated as antifungal therapy. The corneal infiltrate began to resolve and the epithelial defect decreased in size within 2 days. Visual acuity improved to 20/120. After 4 days of voriconazole use, the epithelial defect was completely healed and visual acuity was 20/30 in the affected eye. No fungi were isolated from a second eye scrape. DISCUSSION: Topical voriconazole as salvage monotherapy to manage fungal keratitis has been previously reported. It can be argued, however, that the primary therapy has facilitated the positive response to subsequent topical voriconazole. To date, there has been no solid evidence to suggest that topical voriconazole is effective when used as primary therapy. The current report provides evidence of topical voriconazole demonstrating clinical success when used as first-line therapy to treat C. albicans keratitis. The use of topical voriconazole can reduce the costs, toxicity, and drug interactions associated with common antifungal therapies,

CONCLUSIONS : Topical voriconazole 1 % eye drops administered alone demonstrated success as first - line therapy against the most common fungal keratitis , C .

JOURNAL OF CORNEA , 2009 Sep ; 28 ( 8 ): 856 - 9 .
ulcers . Loh AR, Hong K, Lee S, Mannis M, Acharya NR.

Practice patterns in the management of fungal corneal

PURPOSE : The purpose of this study was to determine the practice patterns of ophthalmologists in the management of fungal corneal ulcers.
METHODS: In December 2007, a survey of 13 questions addressing the actual and preferred treatment of fungal ulcers was sent to the kera-net e-mail listserv facilitated by the Cornea Society. RESULTS : Ninety-two respondents from North America, South America, Asia, Europe, and Australia participated by completing the electronic questionnaire. Natamycin was the most commonly used topical treatment for ulcers caused by filamentous fungi (96%) followed by amphotericin (75%) and voriconazole (63%). However, voriconazole was most often listed as the preferred topical treatment in an ideal world (79%) compared with 55% for natamycin. Approximately half of the respondents use combination topical therapy (56%) and the remainder monotherapy. The majority of respondents rescrape the epithelium at some time during the course of treatment, but the frequency of rescraping varied among the different topical treatments. The most common reasons cited for not using their preferred treatment were cost and a desire for further evidence to support preferred treatment.

CONCLUSION : There appears to be significant variation in the management of fungal corneal ulcers . Although natamycin was the most commonly used treatment for ulcers caused by filamentous fungi , voriconazole was the most preferred as the ideal treatment . These results highlight the need for more evidence regarding the efficacy of the newer topical

Ann Pharmacother . 2009 Jun ; 43 ( 6 ): 1139 - 42 . Epub 2009 May 12. Successful salvage treatment of Scedosporium apiospermum keratitis with topical after failure of natamycin . Al-Badriyeh D, Leung L, Davies GE, Stewart K, Kong D. OBJECTIVE : To report successful management of Scedosporium apiospermum ( previously known as Monosporium apiospermum ) keratitis with topical voriconazole as monotherapy .
CASE well woman presented to the emergency department with a painful, injected right eye. There was no history of trauma or use of contact lenses. On examination, the right eye was estimated movement. Slit lamp examination detected a 2.5 x 3.5 mm dense, central corneal infiltrate with overlying epithelial defect. The eye had mild corneal edema with anterior chamber inflammation. apiospermum as the primary pathogen. Hourly administration of topical natamycin 5% resulted in initial improvement in visual acuity to 20/50, with reduction in the size of the central infiltrate. infection relapsed, with recurrence of epithelial defect (3.1 x 3.1 mm) and decline in visual acuity to 20/100. Antifungal therapy was switched to topical voriconazole 1%, administered every 5 days, and the central defect had completely re-epithelialized within 1 week. DISCUSSION : Treatment of S. apiospermum keratitis remains inadequate. A high natamycin minimum inhibitory apiospermum infection, which may explain the persistence of central infiltration despite ongoing therapy. The combined use of topical and oral voriconazole for the treatment of S. apiospermum However, this is the first report of a successful clinical experience using topical voriconazole without oral therapy to manage S. apiospermum keratitis. This eliminates some disadvantages as high cost, potential significant toxicity, and drug interactions.

CONCLUSIONS : The voriconazole 1 % eye drop used alone is a promising , cost - effective , safe option for managing fungal apiospermum . It may have a larger role to play than simply that of adjunctive therapy .

Journal of Clinical Rehabilitative Tissue Engineering Research . Vol . 13 , no . 18 , pp . 3597 - 3600 . 30 Apr 2009 .
Penetrating keratoplasty for treatment of high - risk fungal keratitis : A 51 - case report Gui-Qiu, Z | Nan, J | Li-Ting, H | Cheng-Ye, C OBJECTIVE : To evaluate the clinical efficacy of PKP in the treatment of high - risk fungal keratitis .

PARTICIPANTS: A total of 51 patients (51 eyes) with high-risk fungal keratitis who underwent PKP in the Affiliated Hospital of Qingdao University Medical College were recruited into this study. Of these patients,12 suffered from perfored, 35 from hypopyon, 8 from complicated cataract prior to surgery, and 5 from complicated glaucoma. METHODS: All patients received antifungal and antibacterial treatments prior to surgery and underwent PKP within 4 days following admission. After surgery,antifungal and antibacterial treatments were performed locally and systemically. All patients werefollowed-up for 6-24 months. Results :( 1) Of 51 patients,18 were followed –up for 6-12 months, 2 for 13-18 months, and 8 for 19-24 months. (2) A total of 49 (96.1%) out of 51 patients preserved the eyeballs and the visual acuity improved to different degrees in 48 (94.1%) patients. (3) After surgery, fungal infection recurred in 6 eyes (11.8%), 4 of which were controlled by antifungal medication and 2 was enucleated because of uncontrolled endophthalmitis. Graft rejection was found in 18 (35.3%) eyes, 13 of which recovered transparent by medication and 5 received secondary PKP. Graftulceration was present in 4 (7.84%) eyes, 3 of which were cured and the remaining one was regrafted because of severe endothelial cell loss. Secondary glaucoma appeared in 7(13.7%) eyes,and the intraocular pressure was controlled medically and surgically. Complicated cataract occurred in 6 (11.8%) eyes, 3 of which underwent cataract extraction. Most complications were successfully controlled. In the final follow-up period, 45 (88.2%) grafts were transparent.

CONCLUSION PKP is an effective approach to preservation of eyeballs and restoration of visual function in patients with high - risk fungal keratitis , which can not be treated by conservative therapy .

Journal of Eye ( 2009) 23 , 477 – 479
Secondary pseudomonas infection of fungal keratitis following use of contaminated natamycin eye drops : a case series . T Krishnan, S Sengupta, P R Reddy,and R D Ravindran Aim : To report a five case of secondary pseudomonas infection of fungal keratitis following use of contaminated natamycin eye drops .

Methods : A retrospective analysis of the course and clinical outcomes of five eyes of five patients with clinical and laboratory-confirmed fungal keratitis species was performed. Clinical worsening despite hourly topical 5% natamycin drops prompted a repeat corneal scraping and microbiological evaluation.Results The causative fungi for the initial keratitis were Fusarium and Aspergillus species. All the five specimens obtained from repeat scrapings revealed Pseudomonas aeruginosa. The cultures obtained from the natamycin eye drops being used by the patients also grew pseudomonas. On further evaluation, the source of contamination of the natamycin containers was obscure but speculated to be nosocomial, being within the hospital or the pharmacy. All patients had a poor visual outcome with one requiring evisceration because of panophthalmitis, whereas three underwent therapeutic keratoplasty.

Conclusions A high index of suspicion is recommended in all cases of worsening fungal keratitis to identify secondary contamination of antifungal agents with nosocomial infections .

Br J Ophthalmol , jan 2009 , vol 93 , issue 1 , pg 116 - 119
and Aspergillus Shelley Day, Prajna Lalitha, Sara Haug, Annette W. Fothergill, Vicky Cevallos, Rajendran Vijayakumar, Namperumalsamy V. Prajna, D Nisha R. Acharya, Stephen D. McLeod, and Thomas M. Lietman. Aims : To study the susceptibility of Fusarium and Aspergillus isolated from keratitis to amoxicillin , cefazolin , chloramphenicol , moxifloxacin , tobramycin , and benzalkonium chloride ( BAK ).
Methods : 10 isolates of Fusarium and 10 isolates of Aspergillus from cases of fungal keratitis at Aravind Eye Hospital in South India were tested using microbroth dilution for susceptibility to amoxicillin, cefazolin, chloramphenicol, moxifloxacin, tobramycin, and BAK. The minimum inhibitory concentration (MIC) median and 90th percentile were determined.Results : BAK had the lowest MIC for both Fusarium and Aspergillus. Chloramphenicol had activity against both Fusarium and Aspergillus, while moxifloxacin and tobramycin had activity against Fusarium but not Aspergillus

Activity of antibiotics against Fusarium

The susceptibility of Fusarium to tobramycin , moxifloxacin , chloramphenicol , and BAK and of Aspergillus to chloramphenicol and BAK may explain anecdotal reports of fungal ulcers that improved with antibiotic treatment alone . While some of the MICs of antibiotics and BAK are lower than the typically prescribed concentrations , they are not in the range of antifungal agents such as voriconazole , natamycin , and amphotericin B . Antibiotics may , however , have a modest effect on Fusarium and Aspergillus when used as initial treatment prior to identification of the pathologic

Major cause of visual loss in tropical regions.  Ocular trauma is the primary risk factor.  Early diagnosis  Effective,Newer drugs

h T

k n a

o y

!! !! u

Sign up to vote on this title
UsefulNot useful