Journal List > J Korean Ophthalmol Soc > v.57(3) > 1010524

Chung, You, Cho, and Ahn: Paecilomyces Keratitis: Cases in Korea and Literature Review

Abstract

Purpose

To analyze the Paecilomyces keratitis cases in Korea and compare cases from foreign literature.

Methods

The records of 3 patients diagnosed with Paecilomyces keratitis at our hospital and other reported cases in Korea were evaluated to examine the predisposing factors, clinical aspects, antifungal therapy, therapeutic surgery, and visual outcome and compared with previously reported foreign cases.

Results

In Korea, 1 patient was female, 4 patients were male and had predisposing factors including prior corneal trauma or surgery, except 1 spontaneous occurrence. All 5 eyes of 5 patients had poor initial visual acuity, less than finger count, and deep corneal infiltration. The patients were treated with multiple topical and systemic antifungal treatments such as intracameral or intrastromal voriconazole injections and required evisceration and penetrating keratoplasty. However, the final outcomes were unsatisfactory. Previously reported cases from foreign literature also had predisposing factors such as corneal surgery, trauma, and soft contact lens use. They were resistant to antifungal therapy and eventually led to surgeries such as penetrating keratoplasty and the final outcomes were poor.

Conclusions

Frequently, Paecilomyces keratitis has direct risk factors and is resistant to many topical and systemic antifungal agents. In the majority of cases, therapeutic surgery was required and the final visual outcomes were poor. When Paecilomyces keratitis is suspected, we suggest aggressive therapy including intracameral and intravitreal injections of voriconazole in the initial treatment.

References

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Figure 1.
Slit-lamp photographs of Case 1. (A) At the initial visit, 4.5 × 4.5 mm sized epithelial defect with a 1.2 mm height hypopyon. (B) After 3 months, corneal lesion regressed with opacity at corneal center.
jkos-57-390f1.tif
Figure 2.
Slit-lamp photographs of Case 2. (A) At the initial visit, 6.0 × 7.0 mm sized epithelial defect with a 1.5 mm height hypopyon. (B) After 2 weeks, epithelial defect was healed with corneal opacity at the center and the infected eye became phthisis bulbi.
jkos-57-390f2.tif
Figure 3.
Slit-lamp photographs of Case 3. (A) At the initial visit, 8.0 × 7.0 mm sized epithelial defect with satellite lesion at the superior. (B) The patient rejected antifungal treatment and returned to hospital with corneal perforation.
jkos-57-390f3.tif
Table 1.
Data from 5 cases of Paecilomyces species keratitis in Korea
No Age (years) Gender Predisposing factor Initial V/A Location Depth Initial size (mm×mm) Hypopyon height (mm) Causative organism Surgical Tx Final V/A Hospital
1 69 F Spontaneous HM Central Deep 4.5 × 4.5 1.2 Paecilomyces species None 0.04 Chonbuk National University (2009)
2 69 M Exposure keratitis HM Central Deep 6.0 × 7.0 1.5 Paecilomyces lilacinus, Staphylococcos epidermidis None NLP Chonbuk National University (2011)
3 72 M Trauma NLP Central Deep 8.0 × 7.0 1.0 Paecilomyces species, Staphylococcus haemolyticus Evisceration NLP Chonbuk National University (2011)
4 67 M Penetrating keratoplasty FC50 cm Central Deep 3.8 × 6.0 Paecilomyces lilacinus Penetrating keratoplasty 0.15 Catholic University (2013)
5 67 M Soft contact lens, diabetes mellitus, cataract operation FC50 cm Central Deep 1.5 × 1.5 Paecilomyces species None Choong-Ang University (1986)

V/A = visual acuity; Tx = treatment; F = female; M= male; HM = hand movement; NLP = no light perception; FC = finger count.

Table 2.
Data from Paecilomyces species keratitis outside Korea
Gender Predisposing factors Topical antifungal agents Systemic antifungal therapy Therapeutic surgery V/A
Yuan et al2 (n = 17) Male (41%)
1. Prior corneal condition or surgery (35%)
2. None (29%)
3. Soft contact lens wearer (24%)
4. Trauma (12%)
1. Natamycin 5% suspension
2. Amphotericin B 0.15% to 0.25%
3. Miconazole 1%
4. Voriconazole 0.2%
1. Oral voriconazole
2. Oral fluconazole
3. Oral ketoconazole
4. IV amphotericin B
1. Penetrating keratoplasty (47%)
2. Enucleation (6%)
1. FC or worse (35%)
2. 20/80 and 20/400 (12%)
3. 20/60 or better (53%)
Yuan et al2 Previous cases review: 20 papers (n = 25) Male (52%)
1. Trauma (36%)
2. Prior corneal condition or surgery (28%)
3. Soft contact lens wearer (24%)
4. None (12%)
1. Penetrating keratoplasty (68%)
2. Conjunctival flap (8%)
3. Enucleation (4%)
Pastor and Guarro1 (n = 15) (Review) Male (40%)
1. Ophthalmic surgery (33%)
2. Previous steroid use (27%)
3. Wearing of contact lenses (13%)
1. Amphotericin B
2. Miconazole
3. Flucytosine
4. Natamycin
1. Amphotericin B
2. Miconazole
1. Loss of vision (26.7%) (Enucleation included)
2. Recovered (46.6%)
3. Not reported (26.7%)
Monden et al5 (n = 4) Male (75%)
1. Diabetes, previous steroid use (50%)
2. Trauma (25%)
3. None (25%)
1. Fluconazole 0.1%
2. Miconazole 0.1%
3. Voriconazole 1%
1. IV fluconazole
2. IV miconazole
3. IV voriconazole
1. Lamellar keratoplasty (50%)
2. Penetrating keratoplasty (25%)
1. 20/100 or worse (50%)
2. 20/25 (25%)
3. 20/20 (25%)
Hirst et al6 (n = 22) Male (68%)
1. None (81%)
2. Minor trauma with no defect (14%)
3. Keratitis (5%)
1. Amphotericin B
2. Voriconazole
3. Natamycin
1. Amphotericin B
2. Itraconazole
3. Ketoconazole
4. Voriconazole
5. Terbinafine
1. Penetrating keratoplasty (59%)
2. Corneoscleral graft (41%)
3. Enucleation (27%)
4. Corneal patch graft (4.5%)
1. NLP (45.5%)
2. LP (4.5%)
3. FC (9%)
4. 6/18, 6/24, 6/60 (23%)
5. 6/9 or better (18%)
Yildiz et al7 (n = 3) Male (67%)
1. Wearing of contact lenses (100%)
1. Natamycin
1. Voriconazole
1. Penetrating keratoplasty (33%)
2. Perforated glue (33%)
1. 20/40 (66.7%)
2. 20/200 (33.3%)
Other previous cases (n = 4)* Male (75%)
1. Wearing of contact lenses (50%)
2. Previous steroid use (25%)
3. None (25%)
1. Voriconazole
2. Amphotericin
3. Natamycin
4. Miconazole
1. Voriconazole
2. Itraconazole
3. Posaconazole
1. Penetrating keratoplasty (75%)
1. 20/200 or worse (50%)
2. 6/36 (25%)
3. 20/60 (25%)

V/A = visual acuity; IV = intravenous; FC = finger count; NLP = no light perception; LP = light perception.

* Other previous cases: Wu et al8, Arnoldner et al9, McLintock et al10, Maier et al11.

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