Incidence and outcomes of Pigmented versus Nonpigmented fungal keratitis - A Retrospective analysis Dr. Thiruvengada Krishnan, M.D. Aravind Eye Hospital.

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Incidence and outcomes of Pigmented versus Nonpigmented fungal keratitis - A Retrospective analysis Dr. Thiruvengada Krishnan, M.D. Aravind Eye Hospital Pondicherry, India Co- Authors –, Dr Deeksha, MD, Dr Sanjeevani, DNB Resident, Dr S. Sengupta, DO Authors have no financial interest Aravind Eye Care System

Aims & Objectives To determine the clinical characteristics and outcomes of dematiaceous (pigmented) fungal keratitis in comparison with that of non-pigmented fungal keratitis by a retrospective analysis.

Materials & Methods Retrospective analysis of 373 culture proven cases of fungal keratitis from January 2006 through August Corneal scrapings collected from the base and edges of the corneal ulcer using a sterile Kimura spatula. KOH mount(10%), and Gram stain,Blood agar and Potato dextrose agar for microbiological diagnosis.

Dematiaceous fungal colonies revealed black or brown pigmentation and Lactophenol cotton blue mount from the culture revealed black or brown pigmented hyphae, conidia, or both. Fungal filaments in KOH Wet mount & slide culture

Culture - colonies Curvularia spsAspergillus flavus Fusarium sps Macroscopic appearance of fungal colonies (hyphae and conidia) on potato dextrose agar.

Fungal isolates A. Non Pigmented fungi % 1. Fusarium %52.34% 2. Aspergillus 9726%37.89% 3. Others 256.7%9.7% B. Pigmented fungi % 1. Curvularia %35.97% 2. Unidentified dematiaceous fungi 215.6%17.9% 3. Others %46.15%

Results & Discussion Non pigmented group Pigmented group Study sample size Male : female ratio MEAN AGE (years) Mean time of presentation5 days Trauma150 (58.59%)62 (52.99%) V/A at presentation (LogMAR) 1.42 ( P value – 0.013) 1.21 On premedication164 (64%) (antifungals %) 63 (53.84%) (Antifungals %) Size of infiltrate14.96mm 2 (p-value ) 10.5mm 2

Cont…. Non pigmented group Pigmented group Location of the infiltrateCentral 140(54.68%) paracentral 67(26.17%) peripheral 29 (11.3%) total 20 (7.8%) Central 51(48.58%) paracentral 46(39.3%) peripheral 11(9.4%) total 9 (7.6% ) Hypopyon130 eyes (50.7%)55 eyes (47%) Macroscopic pigmentation17 eyes (14.5%) Endothelial plaque61 eyes (23.82%)34 eyes (29%) Perforated corneal ulcer28 eyes (10.94%)12 eyes(10.26%)

Treatment given Non pigmented group Pigmented group T opical Rx Natamycin alone Natamycin plus others Topical + Systemic Rx 210 ( 82.03%) 83 ( ) 127 (49.6%) 46 ( 17.97%) 92(78.63%) 45 (38.46%) 47 (40.17%) 25 (21.37%) Duration OF Rx25 days23.5 days Duration of healing4.72 weeks6.53 weeks (p-value=0.023) TPK20 eyes (7.8%)17 eyes (14.5%) (p-value=0.017)

Visual Outcomes Non pigmented gp Pigmented gp Baseline V/A Final V/A p - value p-value<0.0001p-value<0.006 There was a significant improvement in log MAR Visual acuity between baseline and final in both the groups.

Cont… Non pigmented Pigmentedp - value 4 line gainers 29.12% 15.38% p_ Line loosers 1.94%3.84%p_ This shows that, there has been a statistically significant improvement in the visual outcome in the nonpigmented group compared to the dematiaceous group. Significant worsening in pigmented group as well.

Conclusion Pigmented fungal keratitis have an aggressive course, require a higher rate of surgical intervention and have a poorer final visual outcome and have poor prognosis in comparison to nonpigmented fungal keratitis. Prospective Data needs to be generated to manage these cases better.