1. Fungal corneal ulcer after PPKP
Case conference
Fungal corneal ulcer after PPKP
Pf.김만수/St.조경진/R2 한재형

2. Case 2010.8.4(OPD) M/55 Chief complaint : Ocular pain(OD)
VA OD 0.02(n-c)
History
Occupation : Sericulturist (Silk farmer)
Alkalic burn(OD) by Sodium explosion
AMT(OD)
AMT(OD) again due to graft failure
Keratolimbal allograft(OD)
AMT(OD) & Pterygium Excision(OD)
PPKP+ECCE+PCL+tempory AMT(OD)

4. Impression Prescription 1 week follow up
Bacterial keratolimbal ulcer(OD)
Prescription
Fortified vancomycin eye drop 6 times a day
Hyalein mini eye drop frequently
Tarivid eye oint
1 week follow up

5. (OPD)
He revisited complaining decreased visual acuity & aggravating ocular pain!
VA : > FC 30cm(n-c)

7. AC : many cell(++++) & hypopyon
Fundus : Blurry visible

8. Impression : R/O Endophthalmitis(OD) Keratolimbal ulcer(OD) Treatment
Admission
Intravitreal Vancomycin & Fortum injection(OD)
Necrotic limbal tissue removal & conjunctival flap(OD)  culture (OD)  Yeast
Fortified Fortum eye drop q 1hr
Gatiflo eye drop q 1hr
Amphotericin eye drop q 2hr
Hyalein mini eye drop frequently
Atropin eye drop
Systemic antibiotics & antifungal agent(Itraconazole)
Considering Vitrecotmy if vitreous inflammation was not improved

9. 2010.8.9(Hospital day #4) VA : FC10cm
AC : decreased cell(++)
Decreased size of retrolental membranous tissue
Fds : visible disc & posterior pole
Hold vitrectomy

10. 2010.8.10(Hospital day #5) VA : FC30cm
Less ocular pain & partial conjunctival flap loss

11. 2010.8.11(Hospital day #6) VA : FC30cm
Vanishing conjunctival flap

12. Fungus culture : Yeast -> Candida parapsilosis!!!
But we planed to keep eye drop because amphotericin eye drop cover these type of fungi.

13. 2010.8.18(Hospital day #13) VA : FC50cm
A little improvement
Decreased ocular pain
Decreased size of corneal epithelial defect
Decreased stromal infiltration
Almostly diminished chamber inflammation
But still remained keratolimbal ulcer

14. Treatment Second conjunctival graft(OD)
Exchange amphotericin eye drop to voriconazole every 1 hr

15. 2010.8.20(Hospital day #15) POD#1 VA : FC10cm
Intact conjunctival graft
Decreased size of epithelial defect

16. 2010.8.28(Hospital day #23) POD#9 VA : 0.02
Intact conjunctival graft
Decreased size of epithelial defect & conjunctival injection
-> Discharge & keep voriconazole eye drop every 1 hr

17. Decreased inflammation sign But stromal opacity was increased
Cell (+)
(OPD)
Decreased inflammation sign
But stromal opacity was increased
OS : Herpetic scar & ring infiltration was found (VA OS 0.25)
Add Predforte eyedrop 4 times a day (OU)

18. Decreased stormal opacity & injection Well grafted conjunctival flap
(OPD)
Decreased stormal opacity & injection
Well grafted conjunctival flap

19. OS Herpetic scar at center & ring infiltration(OS) much improved
(OPD) OS
Herpetic scar at center & ring infiltration(OS) much improved
VA 0.4 -> 0.8

20. But corneal neovascularization was on going
(OPD)
Decreased opacity
But corneal neovascularization was on going

21. OS Much improved!!! Exchange Predporte eye drop to Ocumetholon
(OPD) OS
Much improved!!!
Exchange Predporte eye drop to Ocumetholon

22. Fungal corneal ulcer after PPKP
Case conference -Review
Fungal corneal ulcer after PPKP
Pf.김만수/St.조경진/R2 한재형

23. 기전 각막 상피 결손 부위를 통해 기질 침입 기질 내 진균 증식 조직 괴사 및 숙주의 염증 반응 유발
침습 진행으로 진균의 데스메막 통과
전방, 홍채, 수정체, 공막까지 도달
혈관이 없어 성장 억제 인자들이 도달하지 못함
진균의 완전한 제거 거의 불가능

24. Introduction
Fungal keratitis is one of the most difficult forms of microbial keratitis for the ophthalmologist to diagnose and treat.
Increasing use of broad spectrum topical antibiotics provide a non-competitive environment for fungi to grow.
Topical corticosteroid use enhances the growth of fungi while suppressing host immune response.

25. Fungus
Fungus gain access into the corneal stroma through a defect in the epithelial barrier.
Once in the stroma, multiply and cause tissue necrosis, host inflammatory reaction.
Penetrate deep into the stroma through an intact Descemet’s membrane.
Organisms gain access into the
anterior chamber or to the iris
and lens, eradication of the
organism becomes extremely
difficult.
Light microscopy showing septate hyphae and spores in the posterior corneal stroma with adjacent inflammatory cells within the anterior chamber (PAS stain, original magnification 200).

26. Risk Factors Trauma - most frequent risk factor.
- most often occurs outdoors and involves plant matter.
- especially in children
: unavailable Hx. , should be cultured for fungi.
Contact lens wearer
- grow within the matrix of soft contact lenses.
- filamentous fungi in cosmetic lens wear.
- yeasts in therapeutic lens uses.
- ? Protective mechanism against fungal invasion into the cornea by the presence of the contact lens.
Topical corticosteroid
- activate and increase the virulence of fungi.

27. Risk Factors Vernal or allergic keratoconjunctivitis
Neurotrophic ulcers d/t VZV, HSV
Incisional refractive surgery
Keratoplasty
- suture problems, topical steroid & antibiotics use, contact lens wear, graft failure, persistent epithelial defect.
- no antifungal is routinely used.
Systemic disease
- DM(usually candida sp.), HIV(+) pt., leprosy…

28. Medical Therapy The principle drugs - 3 groups of compounds
: polyenes, azoles(imidazoles and triazoles), pyrimidines.
Polyenes
- amphotericine B & natamycin.
- natamycin 5% suspension.
: commercially available.
: initial drug of choice for fungal keratitis.
- 0.15% topical amphotericine B
: drug of choice in Candida sp.
: sufficient to treat fungal keratitis and to avoid ocular toxicity.

29. Medical Therapy - if worsening of the keratitis on topical natamycin,
: in Candida sp.
 0.15% topical amphotericin B c/s flucytosine 1%.
: in Aspergillus sp.
 azole(2% fluconazole or 1% miconazole) can be used.
Azoles.
- effective against Candida sp. and Aspergillus sp.
- but not against Fusarium sp.
- Voriconazole
: newer antifungals(systemic use) have been tried topically.

30. Medical Therapy Corneal epithelium
- serves as a barrier to the penetration of most topical antifungal agents.
- debridement of epithelium.
: essential component of the medical management.
: especially early in the course of treatment.
: O’Day et al.
 “corneal debridement significantly increases the antifungal effect of topical antifungals.”

31. Surgical Therapy Debridement
- every 24~48 hrs with a spatula or blade.
- debulking organisms and necrotic materials.
- enhance the penetration of topical antifungals.
Cryotherapy
Intravitreal injections
- if involvement of intraocular structures or endophthalmitis is suspected.
- amphotericin B(5ug/0.1ml) is recommended.

32. Surgical Therapy Conjunctival flap.
- Blood-borne, growth inhibiting factors may not reach the avascular tissues such as cornea, AC, sclera.
- so, fungi continue to grow and persist despite treatment.
 conjunctival flap helps control fungal growth by bringing to avscular tissue blood borne, growth inhibiting factors.
Fig. 86.8A Fusarium keratitis treated with conjunctival flap. A, Preoperative photo. B, Postoperative photo. (Courtesy Mario Brunzini, MD.) Fig. 86.8B Fusarium keratitis treated with conjunctival flap. A, Preoperative photo. B, Postoperative photo. (Courtesy Mario Brunzini, MD.)

33. Surgical Therapy Conjunctival flap.
Refractory ulcerations and necrotic areas heal with scar formation.
Expedites neutralization of proteases.
Provides a source of viable fibroblasts for wound repair.
Provides some degree of tectonic support in thin cornea.
Fig. 86.8A Fusarium keratitis treated with conjunctival flap. A, Preoperative photo. B, Postoperative photo. (Courtesy Mario Brunzini, MD.) Fig. 86.8B Fusarium keratitis treated with conjunctival flap. A, Preoperative photo. B, Postoperative photo. (Courtesy Mario Brunzini, MD.)

34. Key points of this case 1.Endophthalmitis following corneal ulcer
Vitrectomy?
2.Antifungal agent?
3.Graft rejection with PPKP after conjunctival flap

36. Refractory keratitis
-> Voriconazole

37. Graft rejection with PPKP after conjunctival flap
Future treatment -> Re-PPKP