Keratomycosis after incidental spillage of vegetative material into the eye: Report of two cases
A 26-year-old male patient presented with gradual loss of vision in the right eye over the last 2 weeks. The patient had a history of incidental spillage of corn milk while eating corn into his right eye before the onset of his symptoms. There was no history of eye redness or mucopurulant eye discharge after the trauma. He had no history of drug consumption over the last 2 weeks and past medical history was also negative. Visual acuity (VA) had decreased to hand motion in the involved eye. A 5.5 × 6 mm central ulcer with a gray-white dry appearing infiltrate, feathery margin, and satellite lesions characteristic for fungal keratitis was found during eye exam. An additional 1 mm hypopyon was also noted []. Other ocular exams were normal.\nCorneal scraping was done to obtain smear and culture. Although the direct smear stained with gram staining revealed fungal mycelia, the culture became negative for fungus species within Sabouraud's environment.\nThe patient was treated with a high suspicion for filamentous fungal keratitis. Oral ketoconazole (400 mg/day), fortified antibiotic eye drop (voriconazole and amphotricin), topical steroid eye drop (betamethasone, twice daily), and dicloptin eye drop (every 6 h) were prescribed for two weeks. Due to the lack of response to the initial treatment, two intrastromal injections of voriconazole (50 μg/0.1 cm3) were performed within 8 days. The patient was discharged with the aforementioned drugs after relative response with corneal epithelialization and decreased infiltration. Follow-up session after 2 and 4 weeks revealed no better VA than hand motion after the initiation of therapy. The enlargement of the previous ulcer (6.5 × 7 mm) with central thinning, hypopyon of 0.5 mm, and protective ptosis were also evident. Due to no obvious improvement, direct smear and culture was obtained again, which became positive for mycelia and Fusarium species, respectively []. The patient underwent two intrastromal injections of variconazole in 5 days. VA was only light perception afterwards. Two weeks after the last injection, tectonic penetrating keratoplasty was done and the patient was treated with fortified eye drop including amphotericin and natamycin and topical flucortison and chloramphenicol eye drops. Forty days later, the graft was rejected. VA appeared to be as equal to 1 m finger count. Examination revealed suture loosening, corneal edema, infiltration, and keratic precipitates (KPs). The patient was again treated by fortified natamycin, prednisolone (oral: 75 mg/day), and non-preservative steroid eye drop. The next day, suture removal and resuturing was done and topical prednisolone and ciprofloxacin eye drops were added to previously administered drugs. The patient was on treatment for 4 weeks. By the end of the month, edema and infiltration were subsided, VA was increased to 2 m finger count and the patient was discharged with cyclosporine (oral: 200 mg/day) and fortified eye drop (natamycin). During a 2 year follow-up, VA remained unchanged.