1. An analysis of the clinical behavior of mycotic keratitis caused by non sporing molds
Dr. Revathi Rajaraman
Aravind Eye Hospital
Coimbatore
The authors have no financial interest in the subject matter of this poster

2. Purpose
A significant percentage of fungal isolates recovered from keratitis patients fail to sporulate by standard laboratory methods.
This group may consists of established ocular pathogens which behave differently due to unknown reasons and very rare or newer species.
This study analyzes whether keratitis caused by non sporulating filamentous fungi whose species could not be identified, differ in clinical features and response to standard antifungal treatment from that caused by species identified dematiaceous and hyaline fungi.

3. Methods
A retrospective analysis of data collected from case records of culture proven mycotic keratitis between January 2007 December 2008 to assess
- The incidence of NSM keratitis
- The casual relationship between trauma, injuring agents and previous treatment
- Presenting clinical features and response to standard treatment in comparison to those of species identified fungal isolates
Multiple logistic regression analysis was used to find the casual relationship to non-sporulation and associated clinical features and response to therapy was analyzed by Pearson Chi – Square

4. Species Identified & Unidentified by spores
Colony morphology on the solid medium
Spore morphology
A.Flavus
Fusarium semitectum
Aspergillus Flavus
Fusarium semitectum
Dematiaceous Freq
NSDM (non sporing)
Curvularia
Bipolaris
Alternaria
Cladosporium
Collectotrichium
Exerohilum
Lasidiplodia
Nigrosporen 2
Aureobasidum 1
Exophila 1
Total 84
Slide culture LPCB
Hyaline Freq.
NSHM ( non-sporing) 87
Fusarium
Aspergillus 81
Neocosmospora 1
Pencilium 4
Scedosporium 2
Trichothesium 2
Total 414

5. Results - Incidence Isolates NSHM SHM Total Freq Percent 102 20.86 387
FRQU
PERCENT
NSDM 23
22.55
SDM 79
77.45
Total
102
100
FUNGUS
FREQ
PERCENT
NSM
125
21.04 SM
469
78.96
Total
594
100
Isolates
Freq
Percent
NSHM
102
20.86
SHM
387
79.14
Total
489
100
NSM-nonsporing mold,SM-sporing mold, NSDM-non-sporing dematiaceus, NSHM-Nonsporing Hyaline

6. Causative clinical factors for non-sporulation
Variable
Uni variate
Multivariate
OR (95% CI)
P-value
Injury with veg-mater
0.69 (0.45 – 1.08)
0.105
0.47 (0.14 – 1.57)
0.220
Injury with nonveg-mater
1.19 (0.74 – 1.92)
0.474
0.71 (0.22 – 2.24)
0.554
No injury
1.10 (0.73 – 1.66)
0.654
0.64 (0.20 – 2.02)
0.441
Injury with unknown object
1.11 (0.50 – 2.48)
0.791
0.78 (0.26 – 2.34)
0.662
Superficial plaques
0.94 (0.56 – 1.59)
0.816
0.70 (0.34 – 1.42)
0.320
Feathery edged infiltrates
1.02 (0.64 – 1.60)
0.945
0.72 (0.35 – 1.47)
0.361
Full thockness abscess
0.80 (0.48 – 1.33)
0.389
0.77 (0.37 – 1.58)
0.471
Endothelial plaque
0.87 (0.52 – 1.45)
0.592
1.23 (0.68 – 2.22)
0.493
Hypopyon
0.66 (0.44 – 0.99)
0.047
0.68 (0.42 – 1.07)
0.098
Perforated ulcer
0.94 (0.30 – 2.90)
0.909
0.75 (0.21 – 2.61)
0.646
Antifungal
0.79 (0.53 – 1.21)
0.287
0.88 (0.54 – 1.42)
0.594
Antibiotic
1.08 (0.70 – 1.67)
0.724
1.22 (0.75 – 2.00)
0.422
Time lag before treatment
0.69 (0.46 – 1.05)
0.08
0.74 (0.48 – 1.16)
0.188
There is no casual relationship between trauma, injuring agents and previous treatment
Multiple logistic regression analysis of these features, time lag before consultation and clinical features also failed to show any significance

7. Multiple Logistic Regression - Presenting Clinical Features
Non-Sporing & Sporing Dematiaceous Molds
Non-Sporing & Sporing Hyaline molds
In non-sporulating dematiaceous group hypopyon was significantly a rare presentation (P-0.003, OR CI ). Among hyaline fungi there was no difference in clinical features

8. Response to Antifungal treatment
UID - Dematiaceous Fungus HEALED ( P value – )
* UIH - Hyaline Fungus HEALED ( P value – )
*Unidentified demateaceous (NSDM)
* Unidentified Hyaline (NSHM)
Nonsporing Dematiaceous responded relatively better to therapy
Nonsporing Hyaline molds responded similar to other hyaline fungi

9. Discussion
Non-sporulating filamentous fungi constitute significant percentage among keratitis pathogens
No clinically significant causative factor for non-sporulation was found
Non-sporulating dematiaceous group presented rarely with hypopyon and healed better
But hyaline fungi did not showed any difference in presentation and outcome

10. Conclusion
Non-sporing ocular fungal pathogens constitute an interesting area of research
Polymerase Chain Reaction based DNA sequencing of the ocular fungal isolates identified some newer emerging pathogens in addition to established ones
The reason for their non-sporing nature is not clear
Their sensitivity to the existing antifungal agents is yet to be studied
Clinically they behave almost similar to the established filamentous fungi

11. References
R. Bagyalakshmi, K. L. Therese, S. Prasanna, and H. N. Madhavan. Newer Emerging Pathogens of Ocular Non-Sporulating Molds (NSM)Identified by Polymerase Chain Reaction (PCR)-Based DNA Sequencing Technique Targeting Internal Transcribed Spacer (ITS) Region Current Eye Research 2008; 33:139–147
La´szlo´ Kredics, Ja´nos Varga, Sa´ndor Kocsube´, Revathi Rajaraman et al, Infectious Keratitis Caused by Aspergillus tubingensis. Cornea Sep;28(8):951-4
Srinivasan M, Gonzales CA, George C, et al. Epidemiology and aetiological diagnosis of corneal ulceration in Madurai, south India. Br J Ophthalmol. 1997;81:965–971.
Srinivasan M, Fungal keratitis. Curr Opin Ophthalmol 2004 Aug;15:321-7