Demography, Risk Factors, and Clinical and Microbiological Features of Microbial Keratitis at a Tertiary Eye Hospital in Nepal.

BACKGROUND: Infective keratitis is the most common corneal pathology in developing countries. Updated knowledge is needed for its control and proper management. METHODOLOGY: All cases of presumed microbial keratitis that presented in an 18-month period from October 2013 to March 2015 were enrolled. Data collected were demographic profile, risk factors, clinical features, and organisms isolated and their sensitivities. RESULTS: A total of 602 cases of microbial keratitis were enrolled. Mean age of subjects (598 patients) was 47.9 years with 53.8% male. 64.1% worked in agriculture. 38.3% gave history of trauma followed by history of herpetic eye diseases (17.9%) and topical steroid use (14.2%). A total of 473 who were referred came at an average of 21.5 days of symptoms. 14.9% (n=90) of cases were either perforated or impending to perforate at presentation. 69.6% had infiltrate in the visual axis. A total of 516 (85.7%) underwent diagnostic corneal culture. A total of 256 (49.6%) yielded a positive result. Pure bacterial growth was seen in 111 (43.4%), pure fungal growth in 138 (53.9%), and mixed microbial growth was present in 7 (2.7%) cases. Out of 121 bacterial isolates, 95.0% were Gram positive. Streptococcus pneumoniae (45.5%, n=55) was the most common bacterial isolate followed by Staphylococcus aureus (20.6%, n=25). Out of 145 fungal isolates, Aspergillus and Fusarium species were found in equal numbers (n=41, 28.3% each). Over 85% of Gram-positive organisms isolated in the study were sensitive to vancomycin, cefazolin, moxifloxacin, and gatifloxacin. Over 80% of Gram-negative organisms were sensitive to gentamicin, tobramycin, and amikacin. CONCLUSION: Microbial keratitis and associated risk factors occurring in farmers implies a lack of awareness and prevention programs. Delay in reaching tertiary care is resulting in complicated cases. Training of local health workers for prophylaxis, updated guidelines for treating keratitis, and timely referral to higher centers are all important in a chain to decrease the incidence of microbial keratitis.

The Significance of Repeat Cultures in the Treatment of Severe Fungal Keratitis.

PURPOSE: To identify fungal keratitis patients who are at risk of a poor outcome and may benefit from closer follow-up or more aggressive treatment. DESIGN: Secondary analysis of randomized clinical trial data. METHODS: We compared the clinical outcomes of patients who had positive 6-day fungal cultures with those who did not, using backward stepwise regression with covariates for all baseline clinical characteristics. SUBJECTS: Patients presenting with a smear-positive filamentous fungal ulcer and visual acuity of 20/400 or worse, and who subsequently had a 6-day fungal culture performed at the Aravind Eye Care system (India), Lumbini Eye Hospital (Nepal), or Bharatpur Eye Hospital (Nepal). MAIN OUTCOME MEASURES: The primary outcome is rate of corneal perforation and/or the need for therapeutic penetrating keratoplasty. Secondary outcomes include 3-month best spectacle-corrected visual acuity (BSCVA), 3-month infiltrate and/or scar size, and rate of re-epithelialization. RESULTS: Patients who tested positive at their 6-day culture had twice the hazard of experiencing a corneal perforation or the need for therapeutic penetrating keratoplasty (P = .002) than those who tested negative, even after controlling for baseline ulcer characteristics. These patients also had on average 0.26 logMAR lines worse BSCVA at 3 months (P = .001). Culture positivity at day 6 was not a statistically significant predictor of 3-month infiltrate/scar-size (-0.24 mm1; P = .45) or time to re-epithelialization (hazard ratio = .81; P = .31). CONCLUSIONS: Here we identify a uniquely valuable clinical tool, day 6 culture results, for the treatment of severe fungal keratitis. Risk stratification based on repeat culture positivity is an objective way to assess response to medical therapy and identify patients who are at high risk of a poor clinical outcome. This establishes a new standard of care for severe fungal keratitis management.

Telemedicine for corneal disease in rural Nepal.

We evaluated the diagnostic accuracy of slit-lamp photographs interpreted by telemedicine compared to a conventional clinical examination. A convenience sample of 21 patients with anterior segment disease was enrolled at the Lumbini Eye Institute (LEI) in Bhairahawa, Nepal. An ophthalmologist at the LEI examined each patient and assigned a diagnosis and follow-up interval; this represented the gold standard. An ophthalmic technician also obtained anterior segment photographs of each patient. Slit-lamp photographs and clinical histories were then uploaded to a server for access by three separate readers. These readers, one in Nepal and two in the US, provided a diagnosis and follow-up interval independently. The diagnostic agreement between the examiner and all readers was good (kappa = 0.75, P < 0.0001). The agreement regarding follow-up interval between the examiner and all readers was fair, with a kappa coefficient of 0.32 (P < 0.0001). However, the agreement was high when comparing the examiner with the reviewer in Nepal (kappa = 0.90) and was moderate when comparing the two US-based readers with each other (kappa = 0.45). In general, the ophthalmologists in Nepal recommended more rapid follow-up than their US-based counterparts. Our results suggest that the transmission of slit-lamp photographs from satellite clinics and eye health screening camps to the LEI and elsewhere for review and triage is an effective means of identifying anterior segment pathology.