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Another study conducted at University Hospital in Taiwan in 2004 registered the incidence of fungal keratitis in only 13。5% of 476 eyes with microbial corneal ulcer[15], which is quite lower than our study. This variation in the incidence of fungal corneal ulcer confirms the regional difference of mycotic corneal ulcer.
In line with other studies [1618], males (57.1%) are predominant in our study also. The increased risk in males in our country, is probably due to their more active involvement in out door activities, which subsequently increase their vulnerability to this blinding disease.
Incidence of fungal corneal ulcer is almost equal in all age groups in this study which differs from many studies which suggests that fungal keratitis is more common during 50 to 60 years[19].
In the present study, 21.4% patients with fungal corneal ulcer had agriculture trauma, which is lower than described in literature[20]. In some other reports, a frequency of 8.3%[19] to 17.6%[18] has been described for mycotic keratitis in patients with corneal trauma with an organic material which may predispose to the fungal corneal infection.
As in previous study[7], our research also shows higher incidence during the months of October till December followed by March till June. Being an agriculture country, this seasonal variation of the incidence indicates a higher occurrence rate during the harvest season.
The duration from the onset of symptoms to the presentation at our department ranged from 6 to 150 days (mean 62 days).This delay presentation to our tertiary center may be due to the fact that the patient were already receiving therapy from their nearest ophthalmologists and were referred when the ulcers did not respond. Xie et al[7] reported the first visit of 41.0% between 16 and 30 days. We noted that the response to the antifungal therapy was better in the earlier presenters than those very late.
Before reporting to our department, 85.7% patients had received some sort of topical medication including antibiotics, antivirals, antifungals and corticosteroids alone or in combination.
In this study, the most common signs on slit lamp examination were epithelial defect, stromal infiltrate and suppuration found in 100% cases, feathery finger projection and anterior chamber reaction were present in (57.1%) cases, hypopyon in 35.7% patients and satellite lesion in 28.6% eyes. This is in accordance with another Asian study [12] which also showed the epithelial defects (57.1%) and suppuration (57.1%) as the most common signs. Javadi et al[13] noted hypopyon in 52% of eyes with fungal keratitis and Xie et al[7] reported 46.3% incidence.
Rosa et al [3] noted irregular feathery margins (62%) a dry texture (47%) and satellite lesion (47%) in their patients.
In our study 83.3% cases had a positive rate of microscopic examination of corneal scraps with potassium hydroxide 10%, which is nearly similar to the finding of Xie et al[7] (88.7%), and Panda et al[5] (90%). Singh and Choudhary [16]reported a lower rate of 62% where as an incidence of 92.2% reported by Bharathi et al[21]. Chander [22], in their evaluation of Calcofluor white staining for diagnosis of fungal corneal ulcer confirmed the superiority of KOH+CFW in comparison with KOH and culture. In this study positive rate of culture was seen in 67.15% cases which is consistent with the previous studies[23].
In the current study candida (78.6%) was the predominant isolated species. As reported in literature, this species is more common in developed countries[24]. Aspergillus (95g/L) and Fusarium (95g/L) were the next most common species isolated. The study of the literature shows that the Fusarium is a commonly isolated species in North and South China[25] and South India [26].
CONCLUSION
Fungal keratitis is the leading cause of infective corneal ulcer and Candida albicans is the most commonly isolated pathogen responsible for fungal keratitis in Southern Pakistan. The direct microscopic examination with potassium hydroxide 100mL/L method is a simple, rapid, inexpensive and reliable method in the diagnosis of fungal corneal ulcer.
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