Clinical analysis of microbiologically proven fungal keratitis according to prior topical steroid use: a retrospective study in South Korea

Abstract

Background To compare the clinical characteristics and treatment outcomes of microbiologically proven fungal keratitis between users and non-users of prior topical steroids (PS and NPS, respectively). Methods Eighty-three cases with microbiologically proven fungal keratitis between January 2000 and December 2016 were reviewed retrospectively. Diagnosis of fungal keratitis was made through potassium hydroxide smear, culture, PCR, or biopsy. Baseline epidemiology, predisposing factors, clinical characteristics, microbiological profiles, and treatment outcomes were evaluated and compared between the PS and NPS groups. Treatment failure was defined as any case with complications or requiring surgery. The risk factors for treatment failure were evaluated using multivariate logistic regression in the overall cohort. Results A total of 30 cases with PS group and 53 cases with NPS group were included. Of these, sixteen fungal isolates were identified in the PS group and 14 isolates in the NPS group. Candida was the most common organism in both groups (6 cases, respectively), while Aspergillus (4 cases) was found only in the PS group (p = 0.103). No significant differences were observed in the mean age, sex, occupational distribution, epithelial defect size, hypopyon, and presenting best-corrected visual acuity (BCVA) between the two groups. Differences were observed between the PS and NPS groups in terms of previous ocular surface disease (OSD) (43.3% vs. 22.6%, p = 0.048) and deep infiltration (53.3% vs. 32.1%, p = 0.057). Regarding treatment outcomes, final BCVA < 0.1 (60% vs. 44.2%, p = 0.133), the use of voriconazole (topical 10% vs. 0%, p = 0.044; systemic 23.3% vs. 1.9%, p = 0.003), surgical intervention (43.3% vs. 20.8%, p = 0.029), and treatment failure (46.7% vs. 22.6%, p = 0.023) were more common in the PS group than in the NPS group. The significant risk factors for treatment failure were hypopyon (odds ratio [OR] 6.01, p = 0.005) and deep infiltration (OR 4.38, p = 0.013). Conclusions Previous OSD and deep infiltration were more common in the PS group compared to the NPS group. The PS group also experienced worse disease progression and treatment outcomes. These results highlight the need for paying attention to the use of steroids in clinical practice.

Mycotic Keratitis—A Global Threat from the Filamentous Fungi

“…This holds true for prior topical steroid use, which is an independent risk factor for developing fungal keratitis [ 146 ]. Prior topical corticosteroid use is also associated with deeper corneal penetration and a worse clinical outcome [ 147 ]. Although topical corticosteroid use is associated with both yeast and filamentous fungal infections, it may be a stronger risk factor for yeast infection [ 28 ].…”

Clinical profile and treatment outcomes of Fusarium keratitis

“…In a study on fungal keratitis by Cho et al , 36.1% of the study population were using topical corticosteroids previously. [ 31 ] Chowdhary et al . [ 11 ] from north India also reported the use of previous topical corticosteroids in 21% of patients.…”

Topical Corticosteroids and Fungal Keratitis: A Review of the Literature and Case Series

“…NETs are a first-line defense mechanism aimed at reducing the spread of microorganisms and are formed by the association of chromatin, histones, granular, and cytoplasmic proteins released by neutrophils in the extracellular space [65]. The studies that analyzed the role of steroids as a risk factor for worse outcomes in the treatment of fungal keratitis confirm their detrimental effect and conclude that their discontinuation is considered mandatory in cases of suspect or culture-proven fungal keratitis [33,[41][42][43]. However, there are no guidelines regarding how steroids should be discontinued.…”

“…In a retrospective study analyzing a cohort of 83 microbiologically proven cases of fungal keratitis in South Korea, previous use of steroids was associated with a deeper corneal infiltrate, worse disease progression, and inferior treatment outcomes [42]. The patients in this study were divided in two groups: patients with prior use of steroids and patients who had no previous use of steroids before diagnosis of fungal keratitis.…”