Clinical Presentation of Fungal Keratitis

The early lesions of fungal keratitis are quite characteristic. The symptoms are less than what the size would warrant. The symptoms are also less than that of bacterial keratitis of similar size. Some of the characteristic clinical manifestations include, dry raised surface, feathery margins, satellite lesions and posterior corneal abscess. Of these, feathery margins are very typical of fungal corneal ulcers (Figs 2.1 to 2.21).

Fig. 2.1: An early fungal ulcer presenting with very mild congestion and few symptoms. In fungal keratitis the signs are disproportionately higher than the symptoms

Fig. 2.2: Slit lamp photograph of fungal corneal ulcer in the early stages of the infection in which the ulcer is just beginning to progress with the typical feathery margins at the 7’O clock position. The feathery margin is pathognomonic of a fungal corneal ulcer

Fig. 2.3: Corneal ulcer, culture positive for Fusarium, in which the typical broad feathery infiltrate in the anterior stroma are progressing to become broader

Figs 2.4A and B: Fusarium keratitis with endothelial exudates (white fluffy mass in the middle)

forming the appearance of a double layered hypopyon

Fig. 2.5: A culture positive Fusarium keratitis presenting with a central thick plaque with a large hypopyon in the anterior chamber

              Fig. 2.6A: 10 days old fungal corneal ulcer          showing two central (→) and two peripheral satellite (½) lesions

Fig. 2.6B: 10 days old clinical presentation of two feathery edged corneal lesions separated by a clear corneal region. This is an unusual presentation of a satellite lesion, which is usually round in shape

Fig. 2.6C: Satellite lesion which are pathognomic for fungal corneal ulcers (½ Satellite lesion ← Main lesion)

Fig. 2.7: An unusual fungal corneal ulcer that is extending up to the limbus and spreading peripherally towards the temporal aspect.  The  anterior  chamber  is  filled  with  exudates (→ Peripherally spreading fungal ulcer)

Fig. 2.8: Iris prolapse in peripheral fungal ulcer

Figs 2.9A and B: These pictures show an ulcer that is brown (A) black (B) in color and caused by dematiaceous fungi that produce similar pigmentation in culture. Often the clinical presentation might be mistaken for a foreign body in the cornea due to the color and appearance

Figs 2.10A and B: This picture shows a black mass at the inferior edge that might be mistaken for iris prolapse through a perforated cornea. Examination  of this lesion demonstrated this to be a fungal mass caused by dematiaceous fungi

Figs 2.11A and B: This pigmented ulcer was caused by the dematiaceous fungi Lasiodiplodia theobromae an uncommon ocular pathogen. A. Clinical picture, B. Spores of Lasiodiplodia theobromae

Figs 2.12A and B: Fungal corneal ulcer caused by the dematiaceous fungi Bipolaris, in which a white fluffy infiltrate in the stroma can be seen and the surrounding cornea is clear. A. Clinical picture, B. Spores of Bipolaris species

Fig. 2.13: Fungal corneal ulcer caused by the dematiaceous fungi and the pigmentation appear as leopard like brown spots on the ulcer

Fig. 2.14: A clinical presentation of a fungal keratitis with a disproportionately high stromal inflammation. This presentation can mimic a viral keratitis

Fig. 2.15: Fungal corneal ulcer that is involving nearly the entire cornea. These types of presentations are often seen in real life situations. Etiology of the ulcers presenting at this stage cannot be diagnosed by clinical means and often require microbiological investigations to confirm the diagnosis

Fig. 2.16: Fungal corneal ulcers that has involved the entire cornea. The prognosis is poor and would require a penetrating keratoplasty

Figs 2.17A and B: A. Fungal ulcer with active infiltrate. B. Same ulcer showing signs of healing after topical natamycin therapy

Figs 2.18A and B: A. Fungal corneal ulcer due to dematiaceous fungi, with a black mass in the center. B. Superficial keratectomy helps to debulk the fungal mass and also allows better penetration of the drug into the cornea

Figs 2.19A and B: Natamycin (eye drops) deposits (white plaque like structure in the center)

on the cornea in a case of fungal keratitis

Fig. 2.20: Therapeutic keratoplasty done in a case of fungal keratitis

Fig. 2.21: Simultaneous bilateral fungal keratitis caused by different fungi. An interesting case report This was a 60-year- old female patient with lamellar ichthyoses who presented with simultaneous bilateral fungal keratitis caused by different fungi (One pigmented and the other non-pigmented) fungi. The interesting feature was that one eye was affected by Aspergillus and the fellow eye was affected by Curvularia. Although Aspergillus and Curvularia have been reported as causes of fungal keratitis, the simultaneous occurrence in the same patient is a curiosity. The patient was treated with topical natamycin 5 % suspension applied hourly in both eyes for five days and then two hourly. Both ulcers showed signs of healing after 10 days

(Courtesy—Prajna N Venkatesh et al, Simultaneous bilateral fungal keratitis caused by different fungi. Indian J

Ophthalmol 2002;50:213-214.)