Vol.14
No. 1, Januray, 2004
Microbiological
Profile and Management of Infectious Keratitis in An Urban
Referral Centre
Sudesh K Arya, Sunandan Sood, Rajni Nahar, Charu Mithal,
Rajeev Jain
INTRODUCTION
Infectious keratitis accounts for leading cause of corneal
blindness. The spectrum of infectious keratitis is influenced
by factors like age, occupation, geographic area, climatic
condition, rural/urban setting etc. Early management of
these patients can prevent complications and hence blindness.
we retrospectively analysed clinical and microbiological
characteristics of infectious keratitis in an urban referral
centre of north India.
MATERIAL
AND METHODS
A retrospective analysis of 120 consecutive patients of
infectious keratitis visiting Ophthalmology department of
Government Medical College and Hospital, Chandigarh between
June 1999 and June 2003 was carried out.
Analysis
was done in reference to patient's demographic profile,
predisposing factors, duration of symptoms, presenting signs,
microbiological evaluation specially Gram's and KOH stain,
culture sensitivity, treatment given and final diagnosis.
OBSERVATIONS
The average age in our study was 45.15 years with range of
4-75 years. Males outnumbered females by 2.5:1.
There were 86 (71.6%) males and 34 females.
Sixty
nine (57.5%) patients were from rural background while rest
were from urban and semi-urban areas.
Local
predisposing factors were present in 34 (28%) patients. Out of
28 cases of bacterial keratitis, predisposing factors were
present in 12 patients. Injury with vegetative matter
and dust were the commonest predisposing factors (3 patients
each) followed by mechanical trauma (2 patients) and injury
with iron nail (1 patient). One patients was on topical
steroids before coming to us while another patient suffered
from grade III chemical injury and was using bandaged contact
lens. Climatic droplet keratopathy was seen in 01
patients.
Out
of 43 patients of fungal keratitis, 19 had predisposing
factors. 8 patients, had injury with vegetable mater
while 7 patients had injury with dust particles. 3
patients had mechanical trauma with iron nail, buffalo tail
and forceps. One patient was on topical steroids off and
on.
Out
of 43 patients of viral keratitis, 3 patients had local
predisposing factors in the form of injury with iron nail,
injury with dust particles and climactic droplet keratopathy.
4 patients were diabetic while 5 patients had history of
recurrent disease.
Only
24 (20.0%) patients had presented to us as fresh case without
taking any treatment earlier, while rest of patients had taken
some treatment before coming to us. All 24 patients were from
urban areas.
Corneal
scraping were taken in all the patients from Gram's and KOH
stain and the material was also sent for culture and
sensitivity. Positive Gram's staining was seen in 21.4%
of bacterial keratitis cases while KOH staining was positive
in 40% of cases of fungal ulcers.
Cultures
for bacteriae were positive in 10 cases of bacterial keratitis.
Staphylococcus aureus was grown from five cases, pseudomonas
from two, streptococcus pneumoniae from two and E.coli from
one patients.
Out
of 43 cases of fungal keratitis, culture was positive in only
two cases showing growth of fusarium.
Final
diagnosis was made based on combination of clinical
assessment, microbiological report and treatment
response. In our study, bacterial keratitis was
diagnosed in 28 (23.3%) cases, while viral and fungal
keratitis was seen in 35.8% each. 5% of the patients had
mixed infection.
In
the viral group, 09 patients had herpes zoster ophthalmicus.
In
suspected bacterial keratitis cases, treatment was initiated
in the form of fortified cefazolin and amikacin and changed
later according to sensitivity. fungal keratitis cases
were given antifungals in the form of topical natamycin and
oral itraconazole whenever required. Cases of viral
keratitis were given acyclovir eye ointment along with topical
steroids and oral acyclovir if indicated.
In
our study, complications were noted in 12 patients in the form
of perforation and non healing epithelial defects. Rest of the
cases healed with medical management.
Out
of 28 cases of bacterial keratitis, 3 required glue and BCL
application while In another 3, therapeutic penetrating
keratoplasty was done because of large perforations.
Out
of 43 patients of fungal keratitis, 3 patients required glue
with BCL and therapeutic penetrating keratoplasty was required
in 1 patient.
Out
of 43 patients of viral keratitis. BCL application was
required in one while tarsorrhaphy was done in another for non
healing epithelial defects.
DISCUSSION
Infectious keratitis is the leading cause of corneal blindness
in developing countries specially in rural population.
Usually adult male working population is at risk due to
predisposition to trauma specially in fields or at work
place. In our study also, patients from rural background
outnumbered urban patients. This can be attributed to
the fact that urban patients report early for treatment while
rural patients neglect their ailment due to lack of treatment
facilities in their areas. Moreover they are more prone
to injuries also.
In
our study, main predisposing factor was trauma which is
similar to study by Vajpayee et al.3 In western
studies, contact lens wear is the main predisposing factor.
In
fungal keratitis, trauma was the main predisposing factor
which accounted for 32.5% of cases of fungal keratitis.
Trauma with vegetable matter was present in 44.4% of cases in
our series. This is similar to results of Garg et al 4
where vegetable matter trauma was seen in 40% of patients
having trauma.
In
our study culture positivity was present in only 35.7% of
bacterial keratitis and 4.6% of fungal keratitis. This
is very low as compared to studies in western literature where
positivity rate varies from 49-86%. This can be
attributed to the fact that most of the patients already had a
cocktail of antibiotics and antifungals for periods varying
from 7-30 days before presenting to us which might have
decreased culture positivity rate. This is in contrast
to western settings where the first contact of keratitis
patient is a referral hospital.
Commonest
organisms grown were staphylococcus followed by pseudomonas
and streptococci. This is similar to the other Indian
and Western studies.1,3
Incidence
of fungal keratitis in our study was 35.5%. This is
similar to a study from south India where it was reported to
constitute 34% of all cases of infectious keratitis.4
Patients
in our study responded well to standard management protocols
followed in our hospital, only 12 patients developed failure
and required glue application or surgical therapy. The
causes of treatment failure could be delayed initiation of
treatment, resistant to drugs, patients on multidrug therapy,
old age, previous use of topical steroids and systemic
conditions like DM.
CONCLUSIONS
Microbial keratitis requires management by experts only.
On the basis of proper clinical judgement by an expert
treatment must be started immediately. Microbiological
evaluation is must in all the cases before starting any
treatment. Daily monitoring of progress of ulcer is
crucial and management by bandage contact lens,
keratoplasty or amniotic membrane may be needed any time
during the course of the disease.
REFERENCES
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Frederic
S, Olivier B, Leonidas Z, Yan Guix-Crosier bacterial
Keratitis: a prospective clinical and microbiological
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Bourcier, F. Thomas, V Borderie, C Chaumeial, L Laroche.
bacterial keratitis; predisposing factors, clinical and
microbiological review of 300 cases. Br J Ophthalmol 2003;
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Vajpayee
R B, Dada T, Saxena R et al. Study of first contact
management profile of cases of infectious keratitis: a
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Garg
P, Gopinathan V, Choudhary K, Rao G.N. Karatomycosis:
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Morlet
N, Minassian D, Butcher J, and the Ofloxacin study
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Address
for Correspondence
Dr. S.K. Arya, Deptt. of Ophthalmology,
Govt. Medical College & Hospital, Chandigarh.
