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Fungal keratitis is a devastating and difficult-to-treat ocular infection with high morbidity. Understanding geographic microbiological and clinical trends helps to guide rapid and effective treatment. We therefore report the characteristics and outcomes of fungal keratitis in Toronto, Canada over a twenty-year period. An electronic search of microbiology records at University Health Network, Toronto, ON, Canada identified all patients with positive corneal fungal culture over a 20-year period seen at our tertiary referral cornea practice. Review of corresponding patient charts identified demographic and microbiological details, clinical course, treatment regimen, and final outcomes associated with each episode of culture-positive fungal keratitis. Forty-six patients with fifty-one discrete fungal keratitis episodes were included. Five patients experienced recurrent fungal keratitis. Candida species accounted for 60.8% of positive fungal cultures, followed by Filamentous species at 35.3%. Preferred initial anti-fungal treatment was topical amphotericin at 36.7% followed by topical voriconazole at 32.6%. Surgical intervention was required in 48.9% with therapeutic penetrating keratoplasty being the most common procedure (22.4%). Final visual acuity (VA) of < 20/200 was attributed to 58% of patients in this study. Risk factors for poor outcomes included poor VA, topical steroid use at presentation, Candida involvement, history of ocular surface disease, organic ocular trauma, or prior corneal transplantation. Candida is the most frequent keratomycotic pathogen in Toronto. Risk factors for poor visual outcome include prior corneal transplantation, ocular surface disease/trauma, or pre-existing topical steroid use. Early suspicion, diagnosis and treatment are paramount for best clinical outcomes.

A 28-year-old man had experienced binocular diplopia for the last 2 months. Around the same time, he noticed mostly nocturnal polyuria and polydipsia and eventually was diagnosed with diabetes insipidus. Extraocular motility testing demonstrated jerky convergence movements on an attempted upgaze and mild lid retraction (video 1). Urgent MRI of the brain revealed a large mass in the dorsal midbrain region, which was also compressing the hypothalamus (figure). The lesion was biopsied and a diagnosis of primary intracranial germinoma arising from pineal tissue was made. Treatment with low-dose radiotherapy commenced. Characteristic clinical features of convergence retraction nystagmus in this case allowed rapid localization of the lesion, its diagnosis, and eventually treatment.1