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.
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Address for Correspondence
Dr. S.K. Arya, Deptt. of
Ophthalmology,
Govt. Medical College & Hospital,
Chandigarh.
