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Year : 2008  |  Volume : 51  |  Issue : 2  |  Page : 304-306
Keratomycosis in and around Chandigarh: A five-year study from a north Indian tertiary care hospital

1 Department of Microbiology, Government Medical College Hospital, Sector 32, Chandigarh, India
2 Department of Ophthalmology, Government Medical College Hospital, Sector 32, Chandigarh, India

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To find out the prevalence and epidemiological features of keratomycosis in Chandigarh, the present study was carried out jointly by the Departments of Microbiology and Ophthalmology, Government Medical College Hospital, Chandigarh, over a period of 5 years from January 1999 to December 2003. Corneal scrapings were collected from a total of 154 suspected patients of keratomycosis and were processed and identified by standard laboratory techniques. The study revealed that a total of 64 cases (41.55%) were positive for fungal agents. Direct microscopy was positive in 52 cases (76.47%) and culture in 34 cases (53.12%). Most common fungal isolates were Aspergillus species 14 (41.18%), Fusarium species 8 (23.53%), Candida species 3 (8.82%), Curvularia species 2 (5.88%) and Bipolaris species 2 (5.88%). Thus, hyaline filamentous fungi were the most common etiological agents and mechanical trauma with vegetative matter was the most common predisposing factor. Males in age group of 21-50 years were more commonly affected

Keywords: Epidemiology, etiology, fungal keratitis, keratomycosis, mycotic keratitis

How to cite this article:
Chander J, Singla N, Agnihotri N, Arya SK, Deep A. Keratomycosis in and around Chandigarh: A five-year study from a north Indian tertiary care hospital. Indian J Pathol Microbiol 2008;51:304-6

How to cite this URL:
Chander J, Singla N, Agnihotri N, Arya SK, Deep A. Keratomycosis in and around Chandigarh: A five-year study from a north Indian tertiary care hospital. Indian J Pathol Microbiol [serial online] 2008 [cited 2022 Sep 30];51:304-6. Available from:

   Introduction Top

Ophthalmic mycoses are being increasingly recognized as an important cause of ocular morbidity as well as blindness and keratomycosis is the most frequent presentation. [1] In countries having temperate climate such as United Kingdom and northern parts of United States of America, the incidence of mycotic keratitis is very low. [2] But in tropical and sub-tropical countries of the third world, the incidence of mycotic keratitis is more than 50% of all the culture-proven cases of keratitis. [1]

Corneal trauma has been listed as the most common risk factor for mycotic keratitis in most of the studies. Other predisposing factors could be prolonged use of topical corticosteroids or antimicrobial agents, systemic diseases such as diabetes mellitus, pre-existing ocular diseases and use of contact lenses. [1] The etiological and epidemiological pattern of corneal ulceration varies significantly with patient population, health of cornea, geographical region and also tends to vary over a period of time. [2] Therefore, a retrospective study was done over a period of 5 years from January 1999 to December 2003 to find out the epidemiological features and the prevalence of keratomycosis in this area.

   Materials And Methods Top

A total of 154 patients with suspected fungal corneal ulcers presenting in the Out Patient Department (OPD) of Ophthalmology were investigated for fungal etiology in the Department of Microbiology, Government Medical College Hospital, Chandigarh. The ulceration was defined as a loss of the corneal epithelium with underlying stromal infiltration and suppuration associated with signs and symptoms of inflammation with or without hypopyon. Patients with evidence of keratitis due to bacteria, herpes simplex virus and Acanthamoeba species were excluded from this study.

In all these patients, a detailed ocular examination was carried out and the corneal scrapings from the leading edge and base of the ulcers were taken by an experienced ophthalmologist under all aseptic precautions. The samples were sent to the Department of Microbiology immediately. Direct microscopic examination of the corneal scrapping was performed with 10% KOH wet mount and by Gram's staining for the demonstration of fungal elements. Special staining procedure such as Calcofluor White (CFW) staining could not be employed due to unavailability of it.

Another portion of the collected corneal scraping samples was inoculated directly on solid culture media such as blood agar, chocolate agar, Sabouraud's dextrose agar (SDA) without cycloheximide and brain-heart infusion agar (BHIA) without cycloheximide in multiple rows of C-shaped streaks. Inoculation of liquid culture medium brain-heart infusion broth (BHIB) was also done. Blood agar, chocolate agar and BHIA were incubated at 37°C and were examined daily and to be discarded after 7 days, if no growth/turbidity was seen. SDA was incubated at 25°C and 37°C for 4 weeks, whereas BHIA at 37°C for the same period of 4 weeks. These media were checked for any fungal growth in the form of yeast or mycelia, daily during the first week and twice a week for the subsequent 3 weeks. Any growth obtained was further identified by standard laboratory techniques. [3] However, the media were labeled as sterile if no growth was observed even at the end of 4 weeks of incubation and were discarded. The cultures were considered positive if at least one of the following criteria was fulfilled: [4]

  1. The growth of the same organism was demonstrated on one or more solid media and/or if there was confluent growth at the site of inoculation on at least one solid medium.
  2. The growth on one medium was consistent with direct microscopic findings.
  3. The same organism was grown from repeated corneal scrapings.

   Results Top

Out of the total 154 patients, 64 (41.55%) were found to be positive for fungal etiology. Of these, only 52 cases (76.47%) were positive on direct microscopy (showed septate hyphae, pseudohyphae and/or yeast cells) and 34 cases (53.12%) were positive on fungal culture. In each case, there was a single isolate. Mycelial isolates grew in 2-7 days, whereas yeast grew after 18-24 h of incubation. In 30 cases (46.86%), cultures were found to be sterile despite positive direct microscopic findings, but the results were consistent with clinical signs and symptoms of mycotic keratitis. Significant positive cultures were obtained in 12 (17.65%) samples wherein direct microscopy was found to be negative [Table 1]. There were a total of 34 isolates, which included Aspergillus species 14 (41.18%), Fusarium species 8 (23.53%), Candida species 3 (8.82%), Bipolaris species 2 (5.88%), Curvularia species 2 (5.88%) and one isolate (2.94%) each of Aureobasidium pullulans , Paecilomyces species, Penicillium species, Trichosporon species and Rhinocladiella species [Table 2].

Within Aspergillus genus, the following species were isolated in decreasing order - Aspergillus fumigatus in six cases (42.86%), A. flavus in four cases (28.57%) and A. niger in two cases (14.29%). Two isolates of the genus Aspergillus (14.29%) could not be further speciated. In genus Fusarium, species isolated were Fusarium oxysporum 4 (50.00%), Fusarium solani 3 (37.50%) and Fusarium chlamydosporum 1 (12.50%).

All the patients were between the ages of 16 and 90 years, but the age group most frequently affected was that of between 21 and 50 years, 73 cases (47.4%). Male patients, 124 in number (80.52%), were more commonly affected as compared to females. Most of the patients, numbering 118 (76.62%), were from rural background and a majority of them, i.e. 106 (89.83%) were farmers. In the present study, corneal trauma 28 (43.75%) was established as the most common predisposing factor and predominant traumatic agent was vegetative matter 24 (37.50%). Most common agents responsible were thorns 10 (35.71%), paddy grains 8 (28.57%), tree branches 4 (14.28%) and vegetable matter such as sugarcane and grass, 2 (7.14%). History of injury with animals such as cow's tail was also found in one case. Two of the patients had trauma with metallic body and one patient gave history of physical violence. Chronic antibiotic usage and use of topical corticosteroids was seen in 16 (25%) and 5 (7.81%) patients, respectively.

   Discussion Top

Mycotic keratitis occurs much more frequently in developing countries such as India rather than in developed countries. [1] Its incidence is reported to vary from 7% to 40% in various parts of India. [2] In the present study, the incidence was found to be 41.55%, which is in accordance with earlier studies reported from India. [2],[4] Out of the various methods tried during this study for collecting the corneal scrapings and processing of samples, the most successful method that led to minimal contamination and gave consistent results on different media was collecting the corneal scrapings in between two sterile slides.

In the present study, 30 (46.86%) samples remained sterile on culture despite positive direct microscopic findings. These were considered as positive because the direct microscopic findings corroborated with the clinical findings of the patients. The reasons for cultures to be sterile even when the direct microscopy was positive could be that the patients were already using topical steroids or antifungal agents before the corneal scraping samples were taken. Apart from this, many times the sample was so insufficient in quantity that only KOH wet mount preparation could be feasible and inadequate material was left for establishing cultures.

The most frequently implicated fungi in mycotic keratitis appear to vary depending on the geographical location. In the present study, Aspergillus species have been reported as the most frequent cause in consonance with recent studies from the Indian subcontinent. [3],[5],[6] Although in several parts of the world Aspergillus fumigatus is the commonest infective agent, Fusarium species and c0 andida albicans have also been reported as the predominant agents. [7],[8],[9],[10] Dematiaceous fungi have been reported as the third most common cause of keratitis in a number of other studies. [7],[11] In the present study, their ( Bipolaris and Curvularia ) prevalence was found to be 5.88%. In a recently published study from North India, Chowdhary and Singh have reported Curvularia species (29.00%) as the second most common cause of mycotic keratitis after Aspergillus species (41.00%). [6] The rest of fungi reported in the present study, as listed in [Table 2], have been reported in the literature in the past, although very rarely. However, Rhinocladiella species has been observed for the first time.

The fungal corneal ulcers may be reported at any age and in the present study, the age of the patients ranged from 16 to 90 years. However, the most susceptible age group was 21-50 years. In addition, keratomycosis was found to be more common in men than in women. Men, in this age group, have greater exposure to the fungal agents due to maximal outdoor activity.

Corneal trauma has been listed as the most common risk factor for mycotic keratitis. In the present study also, the commonest risk factor was corneal trauma 28 (43.75%) and that too with vegetative matter 24 (37.50%). Other predisposing risk factors were chronic antibiotic usage 16 (25%) and use of topical corticosteroids 5 (7.81%). Reason could be easy over-the-counter availability of these antibiotics and steroid eye drops in our country. Moreover, due to illiteracy, patients keep on using these eye drops continuously for longer periods, many times even without prescription. Eight of the patients gave history of systemic diseases such as diabetes mellitus and tuberculosis. In seven cases, no predisposing factor could be identified. In the present study, not even a single person reported the usage of contact lenses. This is in contrast to a study from Philadelphia, [9] in which the three most common risk factors were found to be chronic ocular surface disease, contact lens usage and use of topical corticosteroids and interestingly, Candida albicans was the most common isolate (46.00%).

Seasonal variations and various environmental factors, such as humidity, rainfall, wind and harvesting of crops, [1] can also influence the incidence of mycotic keratitis. We could not find much association with seasonal changes. However, June, September and November were the months in which the reported prevalence was found to be on higher side, which might be because of harvesting season of crops. Most of our patients hailed from rural background (76.62%) and majority of them (89.83%) were farmers.

In our study, KOH mounts of corneal scrapings were found to be positive in 64.70% (22/34) of subsequently culture positive cases, whereas Gram-stained smears as a diagnostic aid in mycotic keratitis were positive in 55.88% of cases. In a similar study by Srinivasan, [12] it was reported that sensitivity of 10% KOH wet mount was higher (99.23%) than that of Gram-stained smears (88.73%).

   Conclusion Top

Mycotic keratitis continues to be an important cause of ocular morbidity, mostly in the persons inhabiting rural areas, involved in outdoor, agricultural activity. Young male adults affected in these circumstances are often the bread earners of their family and blindness in them is of much grave economic consequences. Therefore, we conclude that early institution of antifungal therapy following meticulous examination of corneal scrapings by direct microscopy at rural centres may limit ocular morbidity and disastrous sequelae among these patients.

   References Top

1.Thomas PA. Current perspectives on ophthalmic mycoses. Clin Microbiol Rev 2003;16:730-97.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Bharathi MJ, Ramakrishnan R, Vasu S, Meenakshi R, Palaniappan R. Epidemiological characteristics and laboratory diagnosis of fungal keratitis: A three year study. Indian J Ophthalmol 2003;51:315-21.  Back to cited text no. 2    
3.Chander J, Sharma A. Prevalence of fungal corneal ulcers in Northern India. Infection 1994;22:207-9.  Back to cited text no. 3  [PUBMED]  
4.Bharathi MJ, Ramakrishnan R, Vasu S, Meenakshi R, Palaniappan R. Aetiological diagnosis of microbial keratitis in South India: A study of 1618 cases. Indian J Med Microbiol 2002;20:19-24.  Back to cited text no. 4    
5.Upadhyay MP, Karmacharya PC, Koirala S, Tuladhar NR, Bryan LE, Smolin G, et al. Epidemiological characteristics, predisposing factors and aetiological diagnosis of corneal ulceration in Nepal. Am J Ophthalmol 1991;111:92-9.  Back to cited text no. 5  [PUBMED]  
6.Chowdhary A, Singh K. Spectrum of fungal keratitis in North India. Cornea 2005;24:8-15.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Srinivasan M, Gonzales CA, George C, Cevallos V, Mascarenhas JM, Asokan B, et al. Epidemiology and aetiological diagnosis of corneal ulceration in Madurai, South India. Br J Ophthalmol 1997;81:965-71.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Hagan M, Wright E, Newman M, Dolin P, Johnson G. Causes of suppurative keratitis in Ghana. Br J Ophthalmol 1995;79:1024-8.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Tanure MA, Cohen EJ, Grewal S, Rapuano CJ, Laibson PR. Spectrum of keratitis at Wills Eye Hospital, Philadelphia, Pennsylvania. Cornea 2000;19:307-12.  Back to cited text no. 9    
10.Omerold LD, Hertzmark E, Gomez DS, Stabiner RG, Schanzlin DJ, Smith RE. Epidemiology of microbial keratitis in Southern California: A multivariate analysis. Ophthalmology 1987;94:1322-33.  Back to cited text no. 10    
11.Gopinathan U, Garg M, Fernandes S, Sharma S, Ananathan Rao GN. The epidemiological features and laboratory results of fungal keratitis: A 10-year review at a referral eye care center in South India. Cornea 2002;21:555-9.  Back to cited text no. 11    
12.Srinivasan M. Fungal keratitis. Curr Opin Ophthalmol 2004;15:321-7  Back to cited text no. 12  [PUBMED]  [FULLTEXT]

Correspondence Address:
Jagdish Chander
Government Medical College Hospital, Sector 32, Chandigarh - 160 030
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.41700

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