Eyeworld

SEPTEMBER 2022 | EYEWORLD | 63 C by Ellen Stodola Editorial Co-Director About the physicians Francis Mah, MD Scripps Clinic La Jolla, California Beeran Meghpara, MD Wills Eye Hospital Philadelphia, Pennsylvania W hen talking about infectious keratitis in the U.S., Francis Mah, MD, said this usually refers to bacterial keratitis, which has a higher incidence than fun- gal keratitis. However, he noted that there are reportedly 30,000–40,000 new cases of fungal keratitis annually, so it's a significant number. There are several issues associated with fungal keratitis, he added. The first is that there is generally a slight delay in making the correct diagnosis. Second, there are not many commer- cially available treatments. "We need to utilize compounding much more frequently for fungal keratitis, which adds to the delay in correct therapy," Dr. Mah said. He pointed out that fungal keratitis, in general, takes longer to resolve and can lead to more visual morbidities, scarring, and long-term vision issues. "In general, although it's less than bacterial keratitis, 30,000–40,000 new cases a year is not insignificant, and it can lead to significant visual morbidity." Different areas will see higher prevalence of fungal keratitis. "The people across the U.S. seeing more fungal keratitis are those in hotter, more humid areas," Dr. Mah said. However, he noted that many corneal specialists think there has been an increase in fungal keratitis across the U.S. Dr. Mah had several thoughts as to why this may be, including contact lens wear. Contact lenses are always going to be a significant etiol- ogy for infectious keratitis, he said, adding that contact lens materials and comfort have gotten better over the years, so more people are able to be fit and wear lenses. This could contribute to the increase in keratitis among contact lens wearers. Dr. Mah also pointed to dry eye as a poten- tial reason for the increase. Many agents for dry eyes are anti-inflammatories. "If you alter the immune system, that may be a possible cause for more infections in the cornea," he said. Beeran Meghpara, MD, agreed that the incidence of fungal keratitis varies significantly around the world, with climate as the key factor. "The incidence is higher in warmer tropical/ subtropical climates versus in cooler climates like here in the Northeast," he said. However, he noted that he still sees a number of these cases at Wills Eye Hospital because it is a large referral center. Depending on the study, Dr. Meghpara said that reported incidence ranges from about 3–800 per 100,000 individuals, so the range is wide. "Anecdotally, it feels like we are seeing more of these in Philadelphia," he said. "We haven't discovered a clear reason for this, but it is likely a combination of less-than-responsible contact lens use, trauma from vegetation, and corticosteroid drop use." How it presents Dr. Meghpara noted that fungal keratitis pa- tients usually present with a slowly progressing corneal infection. "Patients often come to us after seeing multiple eyecare providers and having been on multiple treatments (typical- ly topical antibiotics for a suspected bacterial infection)," he said. "Usually this means they are presenting to us in the later stages of the disease, which is not ideal." Taking a closer look at fungal keratitis continued on page 64 Slit lamp photo of a Fusarium fungal ulcer; note the characteristic non-suppurative, fluffy, multifocal, white infiltrate with intact overlying epithelium and associated hypopyon Source: Beeran Meghpara, MD

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