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Prevent trauma

Tears :Lysozyme, Lactoferrin, ceruloplasmin,B lysin, Complement & Ig`s

Conjunctival follicles & leukocyte defense

ANATOMY

ANATOMY

Rich vascular supply

FUNGAL INFECTIONS OF THE EYE

Presenter: Dr. Vinaykumar Hallur

Moderator: Dr. M.R. Shivaprakash

Periocular Fungal Infections

Mycoses of the Anterior Segment of the Eye

Fungal Endophthalmitis

Laboratory diagnosis

Management

Experimental models

KERATOMYCOSIS

First described by Leber (Aspergillus species) in 1879 Major cause of blindness in Asia Incidence low in Britain & North USA 6-53% of all cases of ulcerative keratitis in Asia Can occur alone or coexist with a bacterial

infection(14.1%) [Basak et al Indian J Ophthalmol. 2005 Jun;53(2):143]

Earlier phaeoid fungi (Dematiaceous) not considered to be significant but now are important cause of keratomycosis .

Rare

EPIDEMIOLOGY

PREVALENCE

North India 82.3%South India 46.1%Eastern India 32.0%Western India 38.9%

Total prevalence of fungal keratitis in India is 30.00% of total cases

Total prevalence of fungal keratitis in western 8.00% countries IJO Sep 2001

South India : 34.4% fungal keratitis, Fusarium 2007 Bharathi et al, Fusarium 43%, Aspergillus 26%, Dematitious Fungi 25% 2003 – Bharathi et al

North India : Aspergillus40% ,Fusarium 16%, Curvularia 8%, 1994- Chander et al.,Aspergillus 35 %, Fusarium 23%, Acremonium 12%, 1993-Chander et al.

AGE 21 -50 YEARS

SEX M > F (3:1)

RESIDENCE RURAL >URBAN

SOCIOECONOMIC STATUS LOW > HIGH

OCCUPATION FARMERS, LABOURER.

SEASONS AUTUMN, RAINY.

Cornea 2000; August:555-59

PREDISPOSING FACTORS• Trauma vegetable matter metallic foreign body sand/stone• Chronic topical medication• Diabetes Mellitus• Topical or systemic corticosteroids• Extended wear/bandage contact lens• Penetrating keratoplasty• Anterior uveitis • Herpes simplex keratitis

ETIOPATHOGENESIS Over 70 genera can cause mycotic keratitis Fungi of importance in microbial keratitis Moniliaceae -- Aspergillus (90%) Most common cause in World -- Fusarium(1%)Second most common cause --Paecilomyces. --Penicillium. --Pseudallescheria. 

Data in brackets from Dept of ophtahlmology, PGIMER

CONTD..

• Dematiaceae. --Curvalaria. (2%) --Alternaria. --Phialophora. --Bipolaris. --Exserohilum. --Cladosporium.-- Colletotrichum • Yeast. --Candida. (2.5%) --Cryptococcus

• Dimorphic fungi. --Blastomyces. --Coccidioides. --Histoplasma. --Sporothrix.

• PATHOGENESIS

-Breach in epithelium-Compromised cornea -Immunocompromised

Contact of fungal hyphae with cornea

Filamentous Yeast

FUNGAL ADHERENCE

Filamentous Fibrinogen receptors on

mature conidia of aspergillus and fusarium

Yeast Integrin analogue, Fibronectin

receptor, Adhesive mannoprotn, Aspartyl

proteinase, Factor 6 , Endo. adhesions.

PENETRATION

Filamentous fungi: Parallel growth of hyphae to stroma, f/b release of mycotoxins, proteolytic enzymes, soluble fungal antigen

Yeast: Proliferate parallel & perpendicular to corneal stroma f/b release of protease and lipase

HOST RESPONSE FILAMENTOUS

inablity of PMN,leucocyte cell for phagocytosis

destruction of corneal stroma

penetrate descement membrane

enterAC accumulate around lens

seclusion of pupil fungal glaucoma

inability of PMN cell to ingest pseudohyphae and hyphae

furstated phagocytosis by PMN

destruction of stroma

melting of cornea

HOST RESPONSE YEAST

CLINICAL FEATURES

• Signs >> symptoms• Manifest within 24 – 48 hours• Patient present within 1st week• EARLY BI-MICROSCOPIC FINDING• Fine or coarse granular infiltrate within the

epithelium and anterior stroma • Minimal stromal infiltrate • Epithelial surface is dry rough textured, dirty gray

in color

CONT………

• Epithelium may be intact or ulcerated.• Pigmented and delicate ,feathery branching

hyphae with surrounding infiltrate• Multifocal suppurative microabsscess or satellite

lesion

CONTD….

• Advanced lesions

o Dense fibrinous material adhering to endothelium and

iris

o Total stromal infiltrate and necrosis

CONTD…………..

• Other signs• White ring (Wessely`s ring)• Conjunctival hyperemia• AC reaction• Hypopyon • endothelial plaque• Mild iritis

YEAST KERATITIS

• Risk Fatcors• Previously compromised cornea• SYSTEMIC DISEASE

Sjogren’s syndrome Erythema multiforme IgA deficiency HIV Endocrinopathy

CLINICAL FEATURE OF CANDIDA INFECTION

• Ulcer is small oval with expanding discrete

sharply demarcated ,dense yellow –white stromal

suppuration

• Feathery margins are not seen

FUNGAL ENDOPHTHALMITIS

a suppurative inflammation of inner ocular

coats and their adjacent structure

with involvement of anterior chamber and

vitreous fluid,

caused by various fungal agents

FUNGAL ENDOPHTHALMITIS

Clinically two types

Endogenous due to hematogenous

spread

Exogenous due to trauma or post

operative

EPIDEMIOLOGY

The first description of endogenous fungal endophthalmitis was by Dimmer in 1913

Candida endopthalmitis clinical entity in 1958

In U.S.A. compared to previous decades Endophthalmitis Increase from last few decades.

Incidence is increasing because of modern medical practices

USA 30 % candidemia(Last 3 decdes) develop endopthalmitis, now there is a lower incidence because of prophylacyic antifungals

CMR, October 2000, p. 662–685

PATHOGENESIS ENDOGENOUS

Multifactorial.

It is likely that sustained fungemia with even

saprophytic fungi can lead to endopthalmitis

Gupte et al -contaminant IV fluids,11 / 72 IV fluid samples

culture positive for fungi

At the time of initial infection with some

dimorphic, fungi, such as H. capsulatum & C.

immitis, unrecognized fungemia occurs and

often leads to endophthalmitis.

ENDOGENOUS ENDOPHTHALMITIS

Predisposing factors Systemic debilitating disease

Malignancy

IVDU

Chemotherapy

Systemic antibiotics

Alcoholism &

Diabetes

PATHOGENESIS ENDOGENOUS

More common in immunocompromised ie pts

on chemo or IV drug abuse

Marked trophism for eye because peculiar

blood supply of the eye.

PATHOGENESIS: EXOGENOUS

Occurs in immunocompetent people

Direct introduction of the organisms following

Surgery(Catarct removal with placement of IOL mainly

Candida spp)

Trauma(Mainly Fusarium spp. )

I/O spread from Fungal keratitis

EPIDEMIOLOGY

RACE – no racial preponderance

SEX – Male preponderance (3:1)

AGE – Young and middle age.

MORBIDITY

Prognosis depends upon virulence of organism extent of involvement timingmode of intervention

Prompt therapy following early diagnosis helps to reduce visual loss

Visual outcome of aspergillus endo. is poor d/t macular involvement.

AGENTSEndogenous Endotphthalmitis

Candia albicans

Fusarium species

Aspergillus species

Histoplasma capsulatum

Coccidioides immitis

Blastomyces dermatitidis

Cryptococcus neoformnas

C. ALBICANS

M.C.C of endogenous endopthalmitis

Infection usually starts from Choroid and then

spreads to retina

Non candida albicans fungemia & endopthalmitis is

increasing and is concern because of antimicrobial

resistance

CANDIDIAL ENDOPTHALMITIS

Current Eye Research, 1–11, Early Online, 2010

ASPERGILLUS ENDOPTHALMITIS

A. flavus second MCC

Spreads from lungs to eye

This is f/b A. fumigatus, A. niger, A. terreus,

A. glaucus , & A. nidulans .

CRYPTOCOCCAL ENDOPH.

Cryptococci spores survive in pigeons

dropping

From lung, fungus – disseminated

haematogenesouly and can affect CNS

causing fungal meningitis &

endophthalmitis in eye

Choroids is the probably first site of ocular

infections

AGENTS

Exogenous Endophthalmitis

Aspergillus spp. C. albicans,C. glabrata, C. tropicalis, C.

parapsilosis Paecilomyces spp. Fusarium spp. Acremonium spp. Curvularia spp.

PRESUMED OCULAR HISTOPLASMOSIS Occurs in immunocompetent individuals

Recognized by presence of multiple atrophic chorioretinal

scars w/o vitreous or aqueous humor inflmn.

Affect 2,000 new individuals a year in areas of endemicity

and in some cases may lead to visual loss and blindness

Arises from hematogenous spread

Not detectable in the scars of POH

Strong epidemiological evidence, principally deriving from

skin test surveys, linking the scars to histoplasmosis

CLINICAL FEATURES

Symptoms

Visual loss Pt. may be asymptomatic if the lesion is in

the peripheral retina Red eye. Photophobia. Pain. Floaters. Scotoma

Many have a classical appearance with

progressive granulomatous uveitis diffuse retinitis deep vitreous abscess.

Time to make diag. from onset of symptoms, 3 d to 4 months.

DEPARTMENTAL DATA

PERIOCULAR INFECTIONS

Palpebral involvement

As a part of generalized or local disease

First reported case 1922 case of sporotrichosis

Tinea faciale

Aspergilloma, sporotrichosis Chalazion

Blastomycosis, Coccidioidomycosis Basal cell

carcinoma

Agent No of cases in literature

Aspergillosis 2

Blastomycosis 12

C. albicans 3

Coccidioidomycosis 6

Cryptococcus spp. 3

Dermatophyte 11

Paracoccidioidomycosis 5

Rhinosporidiosis 7

Sporothrix spp. 5

INFECTIONS OF THE LACRIMAL GLAND

Fungi found to account for only 5% of infections .

14% of cases of congenital dacryocystitis

Principally Aspergillus spp. and C. albicans

implicated

Epiphora is only clinical finding

Lid edema, conjunctival injection, and swelling in the

medial canthus; pressure over the area usually

results in a purulent discharge through the lower

punctumThomas, CMR, Oct 2003,

FUNGAL INFECTIONS OF ORBIT

Proximity of sinuses to orbit, susceptible host & pathogen

Zygomycosis Rhinoorbitocerebral : one-third to one-half of all cases,

Incidence increasing Major risk factor : uncontrolled diabetes mellitus(70% DKA) Other predisposing factors

Chronic alcoholism Renal transplantation Hematological malignancies Steroid therapy Breach of skin

Starts with symptoms consistent with sinusitis Bloody nasal discharge Diplopia and loss of vision

Chakrabarti et al., 2006

INFECTIONS OF ORBIT Invasive aspergillosis

Increased frequency infection :widespread prophylaxis with fluconazole

[VanBurikJH et al. The effect of prophylactic fluconazole on the clinical Spectrum of fungal diseases in bone marrow transplant recipients with special attention to hepatic

candidiasis.Medicine(Baltimore) 1998;77:246−54.]

Exact prevalence of invasive aspergillosis in India is not known [Chakrabarti et al , Japanese Journal of Medical Microbiology vol 49, 165-72, 2008]

INVASIVE ASPERGILLOSIS

Other fungi mimicking aspergillosis Bipolaris spp. Alternaria spp. Curvularia spp. C. immitis B. dermatitidis Histoplasma spp. Penicillium spp.

C/F orbital inflammation & a red proptotic eye with or

without associated pain ophthalmoplegia may develop Embolization of vessels of the optic nerve, or

direct involvement of the nerve may occur

FUNGAL CONJUNCTIVITIS Can occur indepently or with keratomycosis Clinically rare entity Fungi may be present without causing inflammation

in~ 25% pts Topical application tetracycline X 4 wks increased

prevalence 28.7%[Nema, H.V., O.P. Ahuja, A. Bal and L.N. Mohapatra, Effects of topical corticosteroids

and antibiotics on mycotic flora of conjunctiva. Am. J. Ophthal., 1968. 65: p. 747–750].

Topical applications of corticosteroids X 3 wks increase prevalence of fungi 18.8-67%

[Mitsui, Y. and J. Hanabusa, Corneal infections after cortisone therapy. Br. J.Ophthal., 1955. 39: p. 244–250.]

C. albicans follows steroid LA Pseudomembrane Other organisms Aspergillus, Blastomycosis,

Sporothrix, Coccidiodomycosis

EXPERIMENTAL MODELS FK

Albino, wild rabbit , Dutch belted rabbit

Previously immunocompromised corticosteroids locally or systemically

Fractionated cobalt whole-body radiation

administration of antilymphocyte serum

alloxan-induced diabetes

Intra lamellar injection or Superficial

inoculation of spore suspension

CONTD..

IL inoculation : C. albicans, C. krusei, C. tropicalis, C. pseudotropicalis,

Aspergillus spp., Cephalosporium spp., F. solani, Lasiodiplodia

sp.

Superficial inoculation: C. albicans, C. tropicalis, C. pseudotropicalis, Aspergillus spp.,

Allescheria boydii, Cephalosporium spp., Geotrichum sp.

Antibacterial prophylaxis & use of characterized

strain ensures reproducibilty.

IO penetration of ketokonazole in rabbit has been

tried as a therapeutic modaliities

OTHERS

Mice BALB/c mice ip cyclophosphamide 180 mg/kg 1,3, & 5d Scarified corneas /keratoplasty rat cornea in b/w space  topically inoculated Easy handling

Rat Wistar rats or Lewis rats Suitable size & immune response Size of eyes better surgical manipulation

Pigs Large size, ease of fitting contact lens

Owl monkeys Not better than Rabbit keratomycosis model

ENDOPHTHALMITIS MODELS

Rabbits Both immunocompetent and immunocompromised rabbits

are used Used mainly for endogenous endophthalmitis 0.5 ml of 2 X 107 org/ ml into auricular vein intravitreal inoculation of 1,000 CFU of susceptible C.

albicans 

Junko et al Jpn. J. infect. Dis., 60, 33-39, 2007 Mice

Fusarium solani in immunocompetent mice  Inocula of 5 x 10(6) conidia  injected into the lateral tail veinMayayo et al Med Mycol. 1998 Oct;36(5):249-53

DIAGNOSIS

History

Physical examination

Detailed examination of the affected

High risk of suspicion

LABORATORY DIAGNOSIS

Sample collection and transport Biopsy Corneal scraping, corneal button AC tap Vitreous tap Fluids Lens

Swabs not encouraged

Sterile leak proof container ASAP

Delay 4°C with exception of blood and vitreous (30-

37°C ) & swab (15%)

SAMPLES Detailed examination of affected eye using

slit lamp

Tissues diagnostic material harvested by experienced ophthalmologist after LA or SA

Biopsy Scraping :15 Bard – parker surgical blade from the

base & margin(thoroughly) of ulcer aseptically or Kimura’s platinum spatula

Impression smear(Jain et al 2006 – PGIMER, Chandigarh – equally sensitive and specific as Scrappings)

Vitreous tap 300 microL using 23 G needle Aqeous tap 200 microL using 23 G needle

CONVENTIONAL TECHNIQUES

Direct microscopy Rapid and cost effective 10% KOH preparation Gram & Geimsa stain Calcoflour Stain – Easy and fast H&E, GMS, PAS, cytologic preparation

Culture SDA, Blood agar, CHROM agar

Susceptibility testing According to CLSI guidelines

CONVENTIONAL

Nonspecific fluorescent stain – {calcoflour white, blankophor, uvitex 2B} – used in tissue sections and cytopathologic preparation of rapid diagnosis of mycotic

infections. Chander et al. Sensitivity of Calcofluor white – 95.2% compared

to 71.4 % for KOH and culture. fluorescent microscope wavelength of 365 nm.

Acridine orange staining – useful in early diagnosis of keratomycosis

PAS (Periodic acid schiff) stain can also use.

CULTURE

Corneal scraping inoculated on agar plate as a ‘C’ or ‘S’ shaped streak incubated at 25 & 37°C X 4wks

Fungal growth in the form of the streak ensure that the growth is from the inoculum / specimen rather than a laboratory contaminant.

Two sets of SDA with antibiotic, inoculated and incubated at 250 C & 370C separately x 4 wks.

Keeping a possibility of dimorphic fungi

CULTURE

Vitreous fluid inoculated on routine fungal

culture media .

Vitreous sample should be concentrate either

by

centrifugation

Millipore filtration

CULTURE

All the culture checked everyday during first week and twice a week during next 3 week weeks.

Positive culture are more convincing when growth is obtained on more than one

occasion.

CONVENTIONAL TECHNIQUES

Serological techniques

Diagnosis of Histoplasmosis, Blastomycosis

MOLECULAR TECHNIQUES

PCR based detection methods

PCR

Rapid molecular identification of fungal pathogens in corneal samples from

suspected keratomycosis cases. J Med Microbiol. 2006 Nov;55(Pt 11):1505-9.

PCR - SSCP

Sensitive and rapid polymerase chain reaction based diagnosis of mycotic

keratitis through single stranded conformation polymorphism. Am J

Ophthalmol. 2005 Nov;140(5):851-857.

Nested PCR

Comparative study of Gram stain, potassium hydroxide smear, culture and nested PCR in

the diagnosis of fungal keratitis. Ophthalmic Res. 2010;44(4):251-6.

MOLECULAR TECHNIQUES

PCR-RFLP

Diagnosis of Aspergillus fumigatus endophthalmitis from

formalin fixed paraffin-embedded tissue by polymerase chain

reaction-based restriction fragment length polymorphism Indian

J Ophthalmol. 2008 Jan-Feb;56(1):65-6.

Real time quantitative PCR

Detection and quantification of pathogenic bacteria and

fungi using real-time polymerase chain reaction by cycling

probe in patients with corneal ulcer. Arch

Ophthalmol. 2010 May;128(5):535-40.

PRINCIPLES OF TREATMENT

As with any other fungal infection , look & treat

for any predisposing illness

Confirm lab diagnosis

Look for and treat any superadded infection

Remember Poor penetration of antifungal drugs

Corticosteroids are contraindicated

Use both surgical and medical approach whenever needed

Close follow up is required

FUNGAL KERATITIS

Superficial (early keratitis): Topical natamycin (5%) (hyphae) Topical 0.15% amphotericin B or topical fluconazole (yeasts) Debridment of the epithelium

Deeper and larger lesions: Subconjunctival or intravenous miconazole Ketoconazole, itraconazole, fluconazole or voriconazole (p.o.) Intracameral amphotericin B

Surgical treatment: Cyanoacrylate tissue adhesive Amniotic membrane transplantation Penetrating keratoplasty

ENDOGENOUS ENDOPHTHALMITIS

Systemic antifungal agents: Fluconazole,

voriconazole (azole compounds)

Systemic antifungal agents: Amphotericin B:

Parenteral ± intravitreal

Pars plana vitrectomy

EXOGENOUS ENDOPHTHALMITIS

Intraocular (intracameral ± intravitreal) amphotericin

B

Intravitreal voriconazole or miconazole

Subconjunctival antifungal agents: when associated

with keratitis

Systemic antifungal agents: fluconazole,

ketoconazole, voriconazole, itraconazole, miconazole,

and amphotericin B: important in

immunocompromised patients

Pars plana vitrectomy

MUCORMYCOSIS

Radical surgery+ antifungal therapy +

correcting underlying conditions

Amphotericin B Ist DOC(Amphotericin B given

IV at a daily dose of 1.0-1.5 mg/kg infused

during 2-4 hr for a total of 1-4 g)

Lipid formulations of amphotericin B

alternativeFerri: Practical Guide to the Care of the Medical Patient, 8th ed

INVASIVE ASPERGILLOSIS

Voriconazole 6 mg/kg IV q12h for 2 doses,

then 4 mg/kg q12h PO Rx for adults is

200 mg bid or 4 mg/kg bid.

Caspofungin in pts who fail to respond to or

are unable to tolerate other antifungal drugs.

The recommended dosage is 70 mg on the

first day and 50 mg qd thereafter given as a

single dose IV over 1 hr.Ferri: Practical Guide to the Care of the Medical Patient, 8th ed

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