 Okay, we're going to try and get started so that Dr. Mifflin can participate a little bit in the discussion this morning. Our speaker is going to be Adam Guess, one of our cornea fellows, and he's going to speak about fungal keratitis. Thanks. All right. So can you guys hear me okay? Is this our right volume? Yeah. Okay. So I think I know most of you. I'm Adam Guess. I'm one of the cornea fellows this year. And I'll be presenting a case that I took care of along with Dr. Mifflin. And this was an interesting case. I certainly learned a lot from it, so I thought it'd be interesting to you guys. So this is the, you know, so going all the way back, this patient has a fairly extensive history, but this was the first time we saw her. She's a 54-year-old woman who we first saw in 2010. And she has a long history of herpetic infections on the left side of her face dating back to first 18 months of age. And she ultimately developed this interstitial keratitis in her left eye. And when we first saw her, she was presenting for decreased vision in that eye, also some ocular discomfort. You know, on examination, we see corneal vascularization and scarring, some lipid keratopathy, and a fairly pronounced iron line. This lesion was, so first of all, the patient was put on a psychothermia to help try to control herpetic flares, but then this lesion was treated in the operating room with a cauterization of the feeder vessels to try to get these vessels to close down and perhaps limit her erythritic keratopathy. That didn't really help her vision very much. And the next thing that was done was to give her a subconjunction of penelope. Again, trying to get the vessels to close up. This, again, was not successful. She was also treated with subconjunctival abastin, again in the same area, to try to close up these vessels. But ultimately, the patient's vision did not improve very much. And over the course of the next year or so, she ultimately decided to undergo penetrating peritoplastia in this eye. So the graft was done. Her first graft, the surgery proceeded un-eventfully in place with 16 interrupted sutures. And as expected, the path analysis showed some stromal vascularization and some chronic ectinic keratopathy. The post-op course in this patient was difficult due to poor epithelialization. I'm sure that her neurotrophic nature as a herpetic keratitis patient played a role for sure. Particularly, there was this inferral temporal portion of her graft, her surgery. This required the use of bandage contact lenses and, ultimately, a tarsaurofi to try to get the epideffect to close and epithelialize. By post-op month three after this first graft, her epithelium was healed. She did have some residual stromal thinning, especially in that inferral temporal region of her graft. And then off and on, she continued to have sort of sick epithelium. This required off and on bandage contact lens use. Vega mox when she did have epideffects. She was maintained on preservative-free dexamethasone to try to prevent graft projection. And she was maintained on vouchrex to try to keep down any herpetic flares. By post-op month ten, she was doing pretty good. Best corrective vision was 2050, sutures were removed. And then coming forward to October of this last year of 2012, she presented with a red painful eye and had a new large epithelial defect sort of centered around the graft edge near this inferral temporal region. The cornea was markedly thin in that region and the tissue was generally kind of soupy. And basically it was a graft melt that she was experiencing. The graft melt was presumed to be herpetic in nature based on her history of herpetic infections in that eye. She was bumped up to her full treatment dose of acyclovir. She was given topical zirgan, Vega mox for the epideffect and maintained on her dexamethasone. During the couple week course of trying to treat this graft melt, she did develop lesions on her left scalp, which sort of confirmed the thought that this was a herpetic infection, that this was Oster causing this melt. Unfortunately the graft continued to thin and at one point it was so thin we were concerned that perforation was going to happen. So at that point a cynoacrylate glue was applied with a bandage contact lens over the glue. This bought her about a week, but unfortunately about five days later the glue did come off and I perforated. So this resulted in the patient needing to undergo an emergent penetrating keratoplasty. And at 8.75 millimeters so a larger graft place. And Tarsorophy was done at the end of the procedure to try to help prevent some of these epithelialization problems that she had had with her first graft. Following the second PKP, she actually did pretty well in terms of her epithelium. Pathologic analysis somewhat surprisingly showed fungal elements in the excised PKP graft. Cultures were done including fungal cultures at the time of her surgery and didn't show any growth. And the question at that time we had thought and still do I think think that this was a herpetic melt in nature. So the question is whether this fungus was sort of a cohabitant or whether it was at all contributing to her melting graft in that region. And again based on her history and based on those skin lesions we thought this was a herpetic infection leading to the graft melt. The patient following her surgery was actually doing pretty well. She was treated with Durazol, Vigamax. She was on a psychovir sort of a maintenance dose. And then at first using a bandage contact lens to help keep the epithelium in good shape. By post-out month three she was doing pretty well. Her epithelium was intact. The graft was clear. She was not using a contact lens at that point. It was still just on Durazol and a psychovir. So things looking pretty good at that point. Unfortunately about a month later, so this is now February, on a Saturday she calls in because her eyes red and she noticed a concerning white spot on her graft. She's a pretty savvy patient so she knew that that could be a problem. So I saw her over that weekend. And I don't have an image from that day. This is an OR image from a couple of days later so it's not the greatest image. But basically there was kind of whiteness right along the graft. It's sort of a white infiltrate in that whole region. And again that's the region where she had had all of her problems with epithelial healing over the course of her graft. In addition to the infiltrate she had a really intense AC reaction. At least three plus cells. When I first saw her there was no hypopion. Although a couple of days later she did have a hypopion. But probably most concerning she had what appeared to be a fungal ball or hyphal ball sort of floating in the anterior chamber. It's hard to see but it's basically in this region here. And it was sort of this thick circumscribed ball that was sort of adhering to the iris up in that region. So that appearance and the fact that there were fungal elements in the excise graft of course was concerned for a fungal keratitis in this patient. On that days then I performed corneal scraping and culture of this infiltrate. And started the patient initially on voriconazole fortified drops every hour. Oral flu conazole. And I also decreased the durazole from four times a day down to just once a day in case that was playing a role. Also just increased the acyclovir up to her full treatment dose in case her piece was playing a component of this. And this was just before and after I did this scraping. So a couple days later there was still no growth in culture. I guess that wouldn't be surprising if this were a fungus. But there was a lot of increased anterior chamber cell and fibrin. Perhaps due to the fungus proliferating. Perhaps due to decreasing the durazole. Perhaps less corneal infiltrate at that time. The natomycin was added. So natomycin was added to her topical voriconazole that she was already using. And then her oral agent was switched from flu conazole to voriconazole. A B scan done at that time that was a Monday. That showed no posterior involvement. At that time we felt like we really needed to get an isolate, get to know what was going on here. So repeat corneal scraping was done with repeat culture. And this was actually done in the operating room to try to get a really high yield of anterior chamber fluid. We wanted to see if we could get any fungal elements to grow out of the anterior chamber fluid. See if we were able to get that fungal ball out, which I really wasn't. And also to do a lot of PCR testing on the anterior chamber fluid just to see if there was any herpes viruses in the anterior chamber fluid. So then a couple of days later we did get a result. And it was in fact a fungus. A fungus called eulocladium, which was certainly a new one to my experience. Has anyone here had experience with eulocladium before? Okay, this was a new one to me. And I'll go over it's actually quite a rare cause of fungal keratitis, but I'll go over in more detail about it. But it's interesting, both cultures grew the same organism. So the one that was done on that first Saturday and the one that was done a couple of days later, both grew eulocladium. The anterior chamber PCR was negative for the herpes viruses. And then all the gram stain and bacterial plates from those two different days did not grow any bacteria. Did not show any bacteria. And these are just some images from that first excised corneal button showing some of the fungal elements that were identified. This is the susceptibility testing for that organism. You see here that they say there are no guidelines for susceptibility testing for this organism. It's a pretty rare cause of infection. We had at this time the patient on boriconazole, which is shown here, natomycin, which is a polyene. So I guess it may be similar to amphotericin B susceptibility. But during the course of the patient's treatment, she was treated with natomycin boriconazole at one point, amphotericin B was treated with oral fluonazole and oral boriconazole. She's been treated with a lot of different antifungals. About three days later, the patient was looking like this. Basically, the corneal infiltrate actually looked a little better, but the anterior chamber looked really bad. There was a lot of thick fibrinoid material in the anterior chamber, these sort of white fungal balls. This was that one that we first noticed, and then there was a lot of stuff along this area, too. It was suggested at this point that the patient undergo an anterior chamber washout to try to get some of this stuff out of the anterior chamber, followed by injection of amphotericin B and boriconazole. It's an interesting surgery. I have just a quick edited clip of this surgery. Dr. Mifflin performed the surgery. I wasn't present for this, but it was interesting for me to watch the surgery afterwards because just the thick tenacious nature of this fungal stuff in the anterior chamber, I had a lot of experience with these kind of fungus in the anterior chamber, but I was really surprised by how tenacious this stuff was, which I guess explains why it was hard to get that fungal ball out of the anterior chamber just by doing an AC tap that first time. So this is using the binomial of the tractor. You can get a sense that this stuff is pretty thick and adherent. This patient is fake, by the way. Here are just some of this stuff. Yeah, I got just one more little clip of this stuff coming out. I was just really surprised at how thick this was. So anyway, after that, the couple sutures were placed and the patient did, as I mentioned, receive that AC injection of the anterior chamber. So kind of coming forward to now, and I'm glad Dr. Mifflin's here to kind of comment because I haven't seen the patient recently, but per the most recent know, a vision's hand motions. There isn't much infiltrate I'm told and that she still has an epideffect, but it is healing. The anterior chamber looks a lot better and I think she did have a tarsorphy, but now, is the tarsorphy now taken down? No, it's not. Okay. And she's being maintained on now just for conizol four times a day, oral flu conizol, the durazol, vigamox, and a full dose of sycovir. I want to talk a little bit about this specific fungus, but Dr. Mifflin, do you have any comments on the patient or on her care so far? So I want to talk a little bit about this organism because this was certainly a new one to my experience and kind of interesting the more I looked into it. Eulocladium is a filamentous fungus and it tends to be most specifically in the soil and in any kind of decaying or herbaceous plants or agricultural materials. It's also been isolated from papers, textiles, wood. And you know, and the interesting thing, traditionally this organism is considered to cause human disease. It's often considered to be contaminant when it does grow on various cultures, but that view is changing a little bit on this specific organism. And I have some papers to support that. In this case, we don't think it's a contaminant. The same organism grew on both cultures and this was presenting like a fungal carotidus and there was no bacterial growth on any of these cultures. So we do think that this actually did cause her carotidus. And I do have a couple other papers that mention this specific organism causing carotidus. In fact, it's one of the few types of infections that this organism has been reported to cause in immunocompetent patients. One interesting thing about this specific fungus is that because of its non-pathogenic status, it's often used to control them. It's been widely identified in many countries as a result and in fairly high concentrations. So this is an organism that you can pick up or I guess isolate just about everywhere. This was a paper from the Annals of Agricultural and Environmental Medicine and they had pages of tables showing various places that this organism has been discovered in various countries. But I just wanted to point out some of the places in the USA where they've identified this organism. So you see here paint ships and living rooms, carpets, bedspreads and furnitures, floors and home. So this is a pretty widely distributed fungus. You know, it's interesting. I guess the fungus thought to sort of induce plant defenses and that's the reason that they use it to help try to control plant diseases. It also is a competitive inhibitor. It kind of eats some of the same stuff that certain plant diseases eat. So that's why they like to put it on agricultural products. So traditionally, as I said, it's considered to not have pathogenic potential, although, you know, for a while it's been identified in immunocompromised patients causing skin infections. But then more recently there have been increasing reports that it can cause infections in immunocompetent patients. It causes nail infections. This is a report of a sinusitis that was caused by eulocladium. And then as I mentioned, there is a report here of a keratitis happening in immunocompetent patients. I'll go over that in some more detail. So that report is from Bad Knock et al. 2005. And this was a case of an Australian truck driver, a 43-year-old truck driver who really had no prior ophthalmic history and really didn't have any of the risk factors for a fungal keratitis. He had no trauma and no contact lens use, no steroid use. Developed a keratitis. It was initially transferred to a different center where they cultured him and ultimately accrued eulocladium. The patient was then treated with, let's see, hourly fluconazole and natomycin. It was a slow improvement. I mean, it took 24 days for this small ulcer to heal, but ultimately it did heal and he just had a scar left behind and had best-corrected vision of 2020. So this patient did pretty well. They did gene sequencing of the organism that grew and it's interesting. You notice five different species here that are considered 100% or 99.8% sequence similarity. There's a lot of nomenclature problems with this specific organism and a lot of people think that a lot of the different species that are listed are actually just maybe one species. So that's why I think when the microbiologists played it this out, they just called it eulocladium species rather than identifying it. But this was a microbiology journal and they thought that the appearance under the microscope was most consistent with eulocladium atrium for what it's worth. And here's a picture from their paper. This is their organism that they isolated on scraping from their patient. This is our patient. This is from the excised grafts. You see some similarities there. You know, as I mentioned, their patient didn't really have any risk factors for fungal keratitis. He did have a history of tinea pedis and was applying for a result only meant to his feet, so who knows if that's right. But otherwise, not your typical fungal keratitis patient. I did find one other case. I found this looking through my caranet, the corneal email list. And this was a paper published by Marianne and Frank Price and others looking at using collagen crosslinking to treat various different types of infectious keratitis. And they had, you know, they had various pages of tables of different organisms that had been treated. And one of the organisms was eulocladium. This was a 18-year-old female with a pretty small ulcer. You see that the max diameter was just 1.5 millimeters. And the patient recovered quickly after the crosslinking treatment. I did actually email Marianne Price to ask her if they have any more information about this patient or any more information about this organism. And she said, you know, not really. You know, this patient got better quickly and it's not a commonly encountered organism. But we have a couple of papers suggesting that this organism does cause keratitis. And this case, I guess, would be the third reported case as far as I can tell of eulocladium keratitis. One of the questions I had going through my mind as I was researching this stuff is, are fungal infections increasing? You know, in the news a lot lately has been all this stuff from the New England and it's interesting that in their case this organism was another one of these rare human pathogens, you know, that there was only 33 cases reported in the literature prior to this big outbreak. So this was another case where one of these sort of non-pathogenic or rarely pathogenic organisms was causing a lot of human disease. Fungal keratitis in general, the incidence varies widely based on where you are. This is a report from the Proctor Foundation and it just summarized various different other reports talking about the incidence of fungal keratitis. It could be as high as one-third of Miami whereas in California it's probably less than 10%. You know, a study from Madurai India at Aravind showed that pretty much 50% of their cases of keratitis are fungal and nature there. So geography plays a big role. I stumbled upon this paper from Nature when I was researching and it was interesting. They were sort of tabulating all of what they call EIDs, emerging infectious diseases. So what are, you know, new plant and animal diseases that are appearing? And it's interesting that in their tabulated graph here, you know, the huge portion of it, this red part, is fungal. And in fact they break down into 20-year periods here and you see that the incidence of fungal of new fungal infections is increasing dramatically. Who knows if we're just getting better at discovering them or maybe the antibiotics that we're using everywhere are somehow increasing the incidence of fungal infection. This is just the various places where these new fungal infections are appearing. You know, and along these same lines there was this paper from LV Prasad, I Institute in India talking about micro-spiridia, which is again one of these sort of opportunistic or what's classically thought to be an opportunistic fungus. And in their study they found that basically one out of five patients who presents with an infectious keratitis was micro-spiridia. So again suggesting that perhaps some of these organisms might be more common causes of keratitis than is traditionally thought. I wanted to back out a little bit and talk a little bit about just risk factors for fungal keratitis so we can have our clinical suspicions appropriately raised. And this patient basically had almost all of these risk factors. That's the reason to have a high suspicion for fungal keratitis in this patient. We had bandaged soft contact lenses coming on and off the eye. She did have a history of penetrating keratoplasty and I think a lot of this would be on. She did have ocular surface problems. She had chronic epithelial defects that we kind of heal and then we appear again. The patient didn't really have any trauma per se but these are basically the risk factors for what can predispose to a fungal keratitis. In case I'm sure you're all aware but this renewed epidemic was the moisture lock solution that was contaminated with fusarium in 2006. So the medical management of fungal keratitis is challenging. We really don't have an ideal drug to use. The ones that we do use tend to be poorly soluble and tend to be low potency so we need to really increase the concentrations to make them work. And there's a pretty high variability between in vitro and in vivo sensitivity and the other problem is that these fungi can become resistant. Furthermore when you increase the concentrations up enough to have an effect that can often become toxic to the cornea. So we're going to be fortified for Econosol to tell the pharmacist how to make it. I noticed that over the various papers with time the concentration of what's being used has increased like 20 fold from when it was first used. So we're using fairly high concentrations of these antifungals. But the main ones we use typically would be amphotericin B, natomycin and for Econosol. And the types that are used is going to vary by center. There was one study from Mass Eye and Ear and I think natomycin is probably the most widely used just because it's commercially available. And 70% of people who treat fungal keratitis will give the patient an oral agent as well. These are the oral agents that tend to be used. There aren't a lot of studies comparing the antifungal agents and in fact there was a recent Cochrane database review suggesting that there weren't enough randomized control trials to make a big difference. This is one randomized control trial that was done at Aravind Eye Hospital in India. And it was 120 patients. They have a pretty high incidence of fungal keratitis there. Most organisms in their series were fusarium and aspergillus. And basically they found no statistical difference between natomycin and boriconosol. It's interesting they didn't note a nonsignificant trend and by that I mean the p-value was 0.07. So almost significant towards better treatment of the natomycin. And then the other issue they looked at, a lot of people had questioned whether repeat scraping of fungal ulcers results in better healing. And there was a nonsignificant trend meaning p-value of 0.08 suggesting that the ultimate vision was worse with repeat scraping. I did also want to mention one paper talking about surgical treatments for fungal keratitis. It's unclear if this patient will ultimately need a surgical treatment for it. Talking about doing penetrating keratoplasty for, they really included all infectious keratitis. So in their series, for example, 58% was pseudomonas but 32% was fusariums. They did have a fairly high incidence of fungal infection. And basically in their series, people who had ulcers affecting the whole cornea, ulcers encroaching on the limbus were treated surgically. And it's interesting in their series also, so first of all they did large grafts because they tried to get around all of the infected material. And a lot of times they did what's called scleral keratoplasty where they basically saved one quadrant of limbal stem cells and then on the other quadrants they go all the way to the limbus. It's interesting that in their cases of fungal keratitis, they didn't use any steroids for the first several weeks, first one to three weeks, and they did use anti-fungal agents during the first one to three weeks after surgery. So that's something that was not done in this case potentially given the patient anti-fungal treatment as she was recovering but from her keratoplasty. These are just their results. It's kind of a long survival curve, but in essence the one year survival rate for these fungal cases was 72%, that means graft survival, which is pretty good considering that a lot of these cases were perforated or impending perforated. And they did mention in their article too that while the bacterial recurrences tend to happen within days of the graft, fungal recurrences often took weeks or months to show up. And when they did show up, they tended to be kind of an indolent, sort of an endophthalmitus type picture, which is not unlike the way our patient was presenting. So in summary I wanted to present this case because it's a rare cause of infectious keratitis. As far as we know this is only the third case of eulogladium that's been reporting. And fungal keratitis itself is rare, but there is some suggestion that perhaps fungal infections are increasing. I just wanted to also review these risk factors just so all of us can have them in front of our mind. Prior penetrating keratoplasty, any kind of non-healing or chronic FED effect, topical steroid use or soft contact lens use which this patient had all of these. And just I wanted to reiterate the importance of suspecting fungus and not being afraid to culture in these cases. Thanks. Any questions or comments? Oh, uh, several dextrose. Uh, the way the, the way the culture of the fungus. Mm-hmm. You know, maybe Dr. Moshvark can comment on this. When I was in California it was but what would be around our candidate I guess would be another. East, yeah. We see and we take our Boston to see what it would feel like. Thanks. Oh, are you? Yeah, I mean, I could, let me know. The what? Yeah, I mean the LASIC ones. Yeah, thank you. Sounds good, thank you. Yeah, we have two. So, I mean we have the one post-LASIC patient. Run-ups. Yeah. Maybe we should do we should do the LASIC ones. Yeah.