Clinical analysis of microbiologically proven fungal keratitis according to prior topical steroid use: A retrospective study in South Korea

Abstract

Background: To compare the clinical characteristics and treatment outcomes of microbiologically proven fungal keratitis between prior topical steroid users (PS) and no prior topical steroid users (NPS). Methods: Eighty-three cases with microbiologically proven fungal keratitis between January 2000 and December 2016 were reviewed retrospectively. Diagnosis of fungal keratitis was made through potassium hydroxide smear, culture, PCR, or biopsy. Baseline epidemiology, predisposing factors, clinical characteristics, microbiological profiles, and treatment outcomes were evaluated and compared between the PS and NPS groups. The treatment failure was defined as any case with complications or requiring surgery. The risk factors for treatment failure were evaluated on the bases of the total cohort and analyzed using multivariate logistic regression. Results: A total of 30 cases with PS group and 53 cases with NPS group were included. In those, sixteen fungal isolates were identified in the PS group and 14 isolates in the NPS group. Candida was the most common organism in both groups (6 cases, respectively), while the Aspergillus (4 cases) was found only in the PS group (p=0.103). No significant differences were observed in mean age, sex, occupational distribution, epithelial defect size, hypopyon, and presenting BCVA between the two groups. Differences were observed between the PS and NPS groups in the cases of previous ocular surface disease (43.3% vs. 22.6%, p=0.048) and deep infiltration (53.3% vs. 32.1%, p=0.057). Regarding treatment outcomes, final BCVA <0.1 (60% vs. 44.2%, p=0.133), the use of voriconazole (topical 10% vs. 0%, p=0.044; systemic 23.3% vs. 1.9%, p=0.003), surgical intervention (43.3% vs. 20.8%, p=0.029) and treatment failure (46.7% vs. 22.6%, p=0.023) were more common in the PS group than in the NPS group. The risk factors for treatment failure were hypopyon (odds 6.01, p=0.005), deep infiltration (odds 4.38, p=0.013), prior topical steroid use (odds 2.79, p=0.091), and previous ocular surface disease (odds 2.82, p=0.093). Conclusions: The PS group was more associated with previous ocular surface disease and deep infiltration when compared with the NPS group. Treatment progresses and treatment results were worse in the PS group. Careful attention should be paid to the use of steroids in clinical practice.

A prospective study to determine epidemiology, predisposing factors and microbiology of keratitis in north India

“…This has also been observed by several other authors. [3][4][5][6][7][8] Majority of the patients belonged to the middle age group (21 to 60 years), possibly due to the same reason. History of trauma, especially with vegetative matter, maybe an essential risk factor for mycotic keratitis as shown by other authors.…”

“…Indiscriminate use of steroids and antibiotics, use of contact lenses, immuno-compromised state and ocular surgery are other causes of increasing incidence of corneal infection. 3 Agricultural workers and laborers are the biggest occupational group as the highest incidence coinciding with the period of maximal activity. In India, a favorable tropical environment, coupled with a primarily agricultural population having a constant risk of plant exposure and low-income status are the predisposing factors for fungal infections.…”

Bilateral nummular infiltrates: An uncommon presentation of Candida keratitis

“…A recent retrospective chart review of fungal keratitis in a South Korean hospital found prior topical steroid use with worse disease progression, treatment failure, and more commonly necessitating surgical intervention. 14 Cessation of prior topical steroid use in misdiagnosed fungal keratitis presents with its own dilemma as it can further contribute to worsening inflammation and corneal necrosis. 4 Our case further emphasizes risks associated with topical steroid use in atypical cases of keratitis.…”

Therapy for contact lens-related ulcers

“…Voriconazole also has efficacy against yeasts. Corticosteroids have been shown to cause worse clinical outcomes and should be discontinued if a fungal cause is suspected [61].…”