【摘要】 报道1例罕见的被确诊为由镰孢菌属镰刀菌引起的与接触镜有关的严重的真菌性角膜炎，该病例最后通过治疗性穿透性角膜移植术成功治疗。方法：病例报告。结果：一位39岁的马来西亚女士，私企职员，配戴长戴性软性接触镜18a。感右眼剧痛、眼红10d。眼部检查见多个长有伪足的圆形旁中心角膜溃疡，前房少许积脓，临床诊断为真菌性角膜炎。经重复角膜刮片检查真菌和细菌结果均阴性后给予局部广谱抗生素和抗真菌治疗，但患者右眼角膜炎病情进一步加重，又给予其他的局部和全身抗真菌药物治疗，患者右眼角膜溃疡进一步加深。最后，为保留眼球，限制感染，在发病1.5mo后，给予患者治疗性的穿透性角膜移植术。术后，角膜组织病理学检查和PCR检查证实为镰孢菌属镰刀菌感染所致。结论：这是1例罕见的由镰孢菌属镰刀菌感染引起的严重的与接触镜有关的真菌性角膜炎。这也说明了在真菌性角膜炎的治疗上存在挑战性。为控制真菌性角膜炎进一步发展，并保护眼球，治疗性的穿透性角膜移植术应该是最后的选择。
【关键词】 接触镜 真菌性角膜 镰孢菌属镰刀菌
INTRODUCTION
Fungal keratitis is a major blinding eye disease. Ocular trauma and contamination of corneal lesion by soil and plant material are the contributing factors of development of fungal keratitis[13]. Another contributing factor that increases the incidence of fungal keratitis is the widespread use of broad spectrum topical antibiotics and steroid[13]. On the other hand, contact lens related fungal keratitis is surprisingly rarely reported[47].
The US Food and Drug Administration (FDA) approved many types of contact lenses to be worn for either cosmetic reason or therapeutic purposes. Because approximately 125 million of people throughout the world now wear contact lens[8], it is not surprising that many believed that contact lens related keratitis has become an important cause of blindness.
In the present report, we describe a rare case of severe contact lens related fungal keratitis, which had negative result on repeated corneal srapping and did not show clinical improvement with broad spectrum topical antifungal and antibiotic therapy. It was successfully managed with therapeutic penetrating keratoplasty. Fusarium sp was only isolated from histopathological examination and polymerase chain reaction (PCR) of the corneal button.
CASE REPORT
A 39yearold Malay lady, private clerk, was referred to our tertiary eye clinic on August 2005 with 10 days history of right eye redness and pain. She was diagnosed as presumed fungal keratitis by previous ophthalmologist. She received gutt amphotericin B hourly, gutt ciprofloxacin hourly and gutt homatropine three times per day with negative initial corneal scrapping result. She wore extended wear soft contact lens (3.00D) for the past 18 years. She denied any predisposing ocular trauma or engaging in any outdoor activities. She claimed that she practised good hygiene technique in handling her contact lens or did not overnight wear contact lens prior to the symptoms. She denied any history of allergic conjunctivitis or vernal keratoconjuntivitis. No history of misusing any topical steroid. She is a healthy woman without any systemic disease such as diabetes mellitus.
Ocular examination revealed visual acuity of the right eye 6/18 without improvement with pinhole. There was presence of large central corneal ulcer measuring 6.0mm×7.0mm with dense stromal infiltration and feathery edges. There was presence of endothelial striae. Hypopyon less than 1mm was noted in right eye with anterior chamber cell activity of 3+. Lens was clear.
Visual acuity of left eye was 6/36 which was improved to 6/6 Table 1 Published fungal keratitis reports
Reported studyRisk factorsOrganism isolatedSharma et al,2003[4]
IndiaRetrospective review of 28 patients
with contact lens related keratitisContact lens25 bacterial isolated with 52% pseudomonas sp
acanthanoeba(1),herpes simplex virus (1),
aspergillus niger(1)Alfonso et al,1986[5]
Bascom Palmer Eye InstituteRetrospective review of 573 patients from Jan.1977 to Sep.1982Only 21%(118)contact lens cases associated with 64 positive culture40 pseudomonas sp,10 other gram negative bacteria,8 gram positive bacteria, 2 fungi, 3 mixedRosa et al, 1994[6]South FloridaRestrospective review of 120 patients
with fungal keratitis, 10 years from 1982 to 1992Trauma 55(44%),chronic topical medical 16 (13%), diabetis mellitus 15 (12%), topical steroid 9(7%),contact lens 7(5.6%)Fusarium sp (62%), Candida sp (16%),Aspergillus sp (4%),Paecilomyces sp (3.2%),Acremonium sp(2.5%),Curvularia sp (8.7%),Cylindrocarpon sp (1.6%)Tanure et al, 2000[7]Retrospective record of 24 cases of culture positive fungal keratitis from Jan. 1991 to Mar. 1999Chronic ocular surface disease 10(41.7%),contact lens wear 7(29.2%),atopic disease 2(16.7%),topical steroid use 2(16.7%),ocular trauma (8%)Candida albican 11(45.8%),Fusarium sp 6 (25%)
with pinhole.Anterior and posterior segment of left eye examination was unremarkable.General examination revealed normal.
In our center, corneal scrapping for smear and cultures (media:blood agar, saborouds dextrose agar, thioglycolate brotch & chocolate agar) were repeated but the results were negative for bacteria and fungi. Contact lens, its solution and its case were investigated for culture. However, no organism grew. She was treated with intensive broad spectrum antibiotics and antifungal therapy including gutt cefuroxime 50g/L, gutt fortified gentamycin 30g/L and gutt amphotericin B hourly. However, in view of deteriorating of the clinical findings in which hypopyon increased in trend, empirical antifungal topical eyedrops gutt fluconazole, gutt natamycin 50g/L and systemic antifungal oral fluconazole 200mg daily were added. Pressure lowering agents, systemic acetazolamide 250mg four times per day and gutt timolol 5g/L twice per day were also included.
Unfortunately, her right eye presumed fungal keratitis deteriorated further after approximated one and a half months in ward. Larger central corneal infiltration and area of temporal corneal thinning developed. There was no evidence of endophthalmitis. After discussion with patient, a therapeutic penetrating keratoplasty was urgently decided and performed. The donor cornea was trephined 9.5mm to cover the large area of cornea ulcer. Corneal button was sent for histopathological examination, polymerase chain reaction (PCR), culture and sensitivity.
Postoperatively the patient continued with oral fluconazole 200mg daily, gutt amphotericin four hourly, gutt vancomycin 20g/L hourly, gutt ciprofloxacin four hourly and systemic acetazolamide 250mg four times per day, gutt timolol and gutt alphagan twice daily while waiting the laboratory result.
Histopathological examination of the cornea demonstrated septate, nonhyphae fungal keratitis (Figure 1) and PCR from corneal button showed fusarium sp (Figure 2) at 7 days postoperatively. However, corneal button for culture and sensitivity showed negative organism.
Postoperatively, her visual acuity remained good projection and perception of light of the right eye with evidence of cataract. The infection was managed to be controlled with oral fluconazole for two weeks post surgery and topical antifungal
vancomycin and amphotericin B were tapered off for two months. There was presence of deep stromal vascularization of the corneal graft. The clarity of corneal button became better. There was no evidence of recurrence fungal infection noted until the last followup.
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