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Advanced Fusarium Keratitis Progressing to Endophthalmitis

Dursun, Dilek M.D.; Fernandez, Viviana M.D.; Miller, Darlene M.S., M.P.H.; Alfonso, Eduardo C. M.D.

CLINICAL SCIENCES
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Purpose. To review the clinical course, treatment, and visual outcomes of keratitis with endophthalmitis caused by the filamentary fungus Fusarium.

Method. One hundred fifty-nine cases of Fusarium keratitis at Bascom Palmer Eye Institute between January 1, 1987 and August 21, 2000 were reviewed. Ten patients with culture-proven Fusarium keratitis progressed to endophthalmitis. All 10 underwent standard diagnostic microbiologic evaluation, and topical and oral antifungal therapy was instituted. Surgical therapy was applied when necessary. Main outcome measures included the incidence of intraocular invasion of fungal keratitis and response to treatment.

Results. Ten cases of 159 Fusarium keratitis patients had intraocular involvement that was culture proven. The isolated species were Fusarium oxysporum in seven cases and Fusarium solani in two cases, and in one case, the species could not be identified. Cultures of aqueous and intraocular tissues grew Fusarium in eight cases, whereas vitreous cultures were positive in two. Nine cases had preexisting risk factors. All patients received oral ketoconazole or fluconazole and topical natamycin 5%. In two cases, intravitreal amphotericin B injections were also given. Four patients required a penetrating keratoplasty, enucleation was performed in two patients, two patients required a combination of a penetrating keratoplasty and pars plana vitrectomy, and one patient developed phthisis.

Conclusion. The combination therapy with oral imidazoles (fluconazole or ketoconazole) and topical natamycin is inadequate in severe Fusarium keratitis with intraocular spread. Early diagnosis and suspicion of endophthalmitis in patients with keratomycosis not responding to aggressive topical antifungal are important.

From the Department of Ophthalmology (D.D.), Baskent University, School of Medicine, Ankara, Turkey; Department of Ophthalmology (V.F., D.M., E.C.A.), Bascom Palmer Eye Institute, University of Miami, School of Medicine, Miami, Florida, Florida.

Submitted October 22, 2002.

Revision received January 29, 2003.

Accepted February 4, 2003.

Address correspondence and reprint requests to Eduardo C. Alfonso, M.D., Bascom Palmer Eye Institute, 900 N.W., 17th Street, Miami, FL 33136. E-mail: ealfonso@med.miami.edu

© 2003 Lippincott Williams & Wilkins, Inc.