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Triple Infection Keratitis

Ray, Manotosh M.D., F.R.C.S.; Nigel, Lim Chen Siang; Tan, Anna Marie M.R.C.S., M.Med.

doi: 10.1097/ICL.0000000000000022

Objective: To analyze the demographics, risk factors, and clinical and microbiological characteristics of triple infection keratitis.

Design: Retrospective case series.

Participants: Five patients (five eyes) with triple infection keratitis were identified.

Methods: Eyes with polymicrobial keratitis were identified from January 2002 to December 2010. Only culture-positive cases and eyes infected by three different organisms were included. Demographics, risk factors, clinical and microbiological characteristics, and treatment outcomes were analyzed.

Main Outcome Measures: The size of the corneal infiltrate, presence of hypopyon, pre- and post-treatment best-corrected visual acuity, antibiotic regimen and sensitivity, types of isolated pathogens, duration of infection, and treatment outcomes.

Results: The mean age was 39 years (SD, ±23.4; range, 21–74). Use of topical steroids was the commonest risk factor (80%). Multiple risk factors were identified in four eyes. The average size of corneal infiltrate was 23.5 mm2 (SD, ±35.2; range, 2.08–85.5), and all eyes developed hypopyon. A total of 15 organisms belonging to 10 species (bacteria=7, fungi=3) were isolated. Pseudomonas aeruginosa and Candida albicans were the most frequently isolated bacteria (n=3) and fungi (n=3), respectively. All patients had at least one type of fungal isolate. Infection resolved with medical treatment in four eyes and one eye had to be eviscerated as the patient developed panophthalmitis. The average time taken for infection to resolve was 30 days (SD, ±19.3; range, 13–61).

Conclusions: A high index of suspicion of polymicrobial keratitis should be made in patients with multiple and systemic risk factors. Use of topical steroid was the most common risk factor. Prolonged course of disease, relatively large infiltrate, and presence of hypopyon and fungal isolates are typical features of triple infection keratitis.

Department of Ophthalmology (M.R., A.M.T.), National University Health System, Singapore, Singapore; and Yong Loo Lin School of Medicine (M.R., L.C.S.N., A.M.T.), National University of Singapore, National University Health System, Singapore, Singapore.

Address correspondence to Manotosh Ray, M.D., F.R.C.S., Department of Ophthalmology, National University Hospital, 1E, Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, Singapore 119228; e-mail:

The authors have no funding or conflicts of interest to disclose.

Accepted January 16, 2014

© 2014 Contact Lens Association of Ophthalmologists, Inc.