1. Elvin H. Yildiz, Yasmine F. Abdalla, Ahmed F. Elsahn, Christopher J. Rapuano, Kristin M. Hammersmith, Peter R. Laibson, Elisabeth J. Cohen Cornea Service, Wills Eye Institute, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA. Elisabeth J. Cohen, MD was paid by lawyers representing patients against Bausch & Lomb Elvin H. Yildiz, Yasmine F. Abdalla, Ahmed F. Elsahn, Christopher J. Rapuano, Kristin M. Hammersmith, Peter R. Laibson, Elisabeth J. Cohen Cornea Service, Wills Eye Institute, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA. Elisabeth J. Cohen, MD was paid by lawyers representing patients against Bausch & Lomb

2. Purpose To evaluate the number of cases, risk factors, treatment and prognosis of fungal keratitis during the period from April 1999 to the end of 2008, at Wills Eye Institute, in order to put the recent Fusarium outbreak into a broader context. To update the trends and outcomes of fungal keratitis at our institute since the study by Tanure et al ten years ago. 1 1 Tanure MA, Cohen EJ, Sudesh S, Rapuano CJ, Laibson PR. Spectrum of fungal keratitis at Wills Eye Hospital, Philadelphia, Pennsylvania. Cornea 2000; 19: 307-12.

3. Materials and Methods * All patients diagnosed with fungal keratitis presenting to the Cornea Service at Wills Eye Institute between 4/1/1999 and 12/31/2008 were identified through a computerized diagnosis code search of our patient database. * Demographic data, clinical features, microbiology and/or pathology results were analyzed. * Predisposing risk factors were identified, including trauma and contact lens use. * A Fisher’s exact test and an exact logistic regression test were used to determine whether there was a change in the rate of CL related infections over time (from 1999 to 2008). * Relative risks for contact lens related Fusarium keratitis between 2005- 2006 and 2007-2008 were estimated.

4. Results Seventy-eight eyes of 76 patients were identified (one patient had an infection in each eye one year apart and one had simultaneous bilateral infections) * 41 females (53.9 %), 35 males (46.1%) * The mean age was 58.0± 19.3 years (range 19 – 89 years) * The use of contact lenses was the most common risk factor for fungal keratitis, present in 28 eyes (35.9%). * A history of trauma (17 eyes, 22.4%), PK (12 eyes, 15.8%), or herpetic eye disease (9 eyes, 6 herpes simplex and 3 herpes zoster, total 11.5%) were also common risk factors in our series. * Fusarium was isolated in 17/28 (64.3%) contact lens related infections (Table 1). * The clinical presentation of our patients was variable. Non-specific infiltrates were present in 46 eyes (58.9%). * Typical finding of fungal infections were present in 12 eyes with a feathery infiltrate (15.4%) and in 11 eyes with satellite lesions (14.1%) (Table 2).

5. Table 1: Contact lens related fungal keratitis cases; risk factors and causative organisms. YearCaseOrganismContact lensSolutionOverwear/EW 19991FusariumSCLunknown+ / - 20012FusariumRGP- / - 3TrichosporumFocus N&Dunknown - / - 20044AspergillusAcuvue EWunknown - / - 5FusariumSCLunknown+ / - 6FusariumEWunknown - / - 20057FusariumAcuvue2Complete- / - 8NegativeAcuvue2unknown- / - 9FusariumFR ReNu ML ̽ - / - 10FusariumFRReNu ML- / - 11FusariumAcuvue2unknown 12FusariumAcuvue2unknown- / - 13FusariumAcuvue2ReNu ML- / + 14FusariumAcuvue2ReNu ML- / - 200615FusariumConventionalReNu ML- / - 16FusariumSCLunknown- / - 17FusariumAcuvue2ReNu ML- / - 18FusariumAcuvue2ReNu ML- / - 19AspergillusAcuvue OasysReNu- / - 200720FusariumSCLReNu ML- / - 21FusariumAcuvue2ReNu- / - 22CandidaHydroclearReNu- / - 200823PaecilomycesunknownOptifree replenish- / + 24AltenariaAcuvue 2ReNu Multi-Purpose 25AltenariaOasys-AcuvueReNu Multi-Purpose- / + 26BipolarisUnknown 27 PaecilomycesAcuvue 2 28 PaecilomycesFROptifree- / +

6. Table 2:The presenting features of the eyes Clinical presentationNumber of eyes (%) Frank epithelial defect 57 (73.1) Infiltrates Non specific 46 (58.9) Feathery 12 (15.4) Satellite 11 (14.1) Immune Ring 4 (5.1) Peripheral Infiltrate 2 (2.6) Hypopyon 28 (35.9) Anterior chamber reaction 13 (16.6) Intact epithelium 9 (11.5) Endothelial plaque 8 (10.2) Corneal melting 3 (3.9) Dendritiform epithelial lesion 2 (2.6) Epitheliopathy 2 (2.6) Endophthalmitis 2 (2.6)

7. Results Sixty-six cases (86.8%) had positive cultures. Fusarium was the most common organism, isolated in 29/78 eyes (37.2%), 17 of which (58.6%) were contact lens wearers. Other filamentous fungi were isolated in 15 eyes (19.2%). Candida and other yeasts were isolated from 22 eyes (28.2%) (Table 3). Eleven patients were culture negative but, there was a strong clinical evidence of fungal infection with a favorable response to antifungal therapy, after failure of antibiotics. Histopathology was positive for fungal organisms in 3 of these 11 culture negative patients. Although it is difficult to identify fungal species by histological criteria, PAS stain disclosed rare fungal elements described as yeast in 2 culture negative cases.

8. Table 3:Culture results OrganismNumber Fusarium29 Alternaria3 Paecilomyces3 Aspergillus2 Curvularia2 Scedosporium apiospermum2 Unidentified filamentous2 Wangiella1 Total filamentous44 Candida albicans17 Candida parapsilosis2 Malassezia furfur1 Trichosporon1 Unidentified yeast1 Total yeasts22

9. Results There was a significant increase in contact lens-related Fusarium infections over time (p = 0.021) with the highest numbers in 2005-2006, but no analogous trend over time for Candida (p =1.00) or other fungal infections (p = 0.577) (Table 4). The odds of having a contact lens related Fusarium infection in 2005-2006 compared to 2007-2008 were 4.40 (95% confidence interval of 0.60 to 32.50, p=0.178). Despite the decrease in contact lens related Fusarium infections, the number of fungal infections remained elevated in 2007 (10 eyes) and 2008 (14 eyes), including contact lens related infections (3 in 2007, 6 in 2008). In 2008 there were 3 contact lens related Alternaria infections and 2 contact lens related Paecilomyces infections.

10. Table 4: Fungal infections by year Years Number o f cases Fusarium CL related non CL related Candida CL related non CL related Others CL related non CL related 1999 1100000 2000 5020111 2001 4100102 2002 3010101 2003 2000200 2004 7200212 2005 12720201 2006 11430211 2007 8201401 2008 14041252 Total 67 * 17122 17 8 11 * Culture negative cases (11/78, 14.1%) are not included.

11. Conclusion A definite increase in the number of fungal keratitis cases began in 2004 and continued through 2006 during the Fusarium outbreak associated with ReNu with Moisture Loc. In spite of the decrease in contact lens- related Fusarium infections, the overall number of fungal keratitis cases remained high through 2008. Fungal keratitis was more often associated with contact lens use than with trauma in this time period.