Microsporidial Stromal Microsporidial Stromal Keratitis : Dilemma in Keratitis : Dilemma in

Clinical DiagnosisClinical DiagnosisSwapnali Sabhapandit, MSSwapnali Sabhapandit, MS

Prashant Garg, MDPrashant Garg, MDSomasheila Murthy, MSSomasheila Murthy, MSGeeta K Vemuganti, MDGeeta K Vemuganti, MD

Ashok K Reddy, PhDAshok K Reddy, PhD

LV Prasad Eye Institute Hyderabad, IndiaLV Prasad Eye Institute Hyderabad, India

Authors have no financial interestAuthors have no financial interest

Ubiquitous, intracellular, Ubiquitous, intracellular, eukaryotic, spore forming eukaryotic, spore forming parasiteparasite

Opportunistic pathogenOpportunistic pathogen

Systemic infectionsSystemic infections

Immuno-compromised Immuno-compromised patientspatients

MicrosporidiaMicrosporidiaMicrosporidiaMicrosporidia

KeratoconjunctivitisKeratoconjunctivitis

Stromal keratitisStromal keratitis

Clinical presentation :

MicrosporidiaMicrosporidiaMicrosporidiaMicrosporidia

- Uncommon- Uncommon

- 13 cases reported- 13 cases reported

05 cases reported from LVPEI05 cases reported from LVPEI

- Immuno-competent- Immuno-competent

Retrospective consecutive case Retrospective consecutive case

seriesseries

January 2002 – December 2009January 2002 – December 2009

Study design :

- Detailed clinical examination- Detailed clinical examination

- Microbiology work-up- Microbiology work-up

- Pathology of excised corneal - Pathology of excised corneal

tissuetissue

Microsporidial stromalMicrosporidial stromal keratitis keratitis

Microsporidial stromalMicrosporidial stromal keratitis keratitis

AgeAge :: 2 to 77 years2 to 77 years

M:F M:F :: :: 17:717:7

Duration of symptoms : 30 - 1460 daysDuration of symptoms : 30 - 1460 days

Results:Results:

Microsporidial stromal Microsporidial stromal keratitiskeratitis

Microsporidial stromal Microsporidial stromal keratitiskeratitis

17 had symptoms > 60 days 17 had symptoms > 60 days 10 of these had symptoms > 1 year10 of these had symptoms > 1 year

Trauma (n = 10)Trauma (n = 10)

Contact lens (n = 1)Contact lens (n = 1)

No predisposing factor (n = 13)No predisposing factor (n = 13)

Predisposing factorsPredisposing factors

Microsporidial stromal Microsporidial stromal keratitiskeratitis

Microsporidial stromal Microsporidial stromal keratitiskeratitis

Results:Results:

Pre-presentation diagnosisPre-presentation diagnosis

HSV keratitis (n = 10)HSV keratitis (n = 10) HSV or fungal (n = 5)HSV or fungal (n = 5) Fungal (n = 4)Fungal (n = 4)

Clinical picture at presentationClinical picture at presentation

Microsporidial stromalMicrosporidial stromal keratitis keratitis

Microsporidial stromalMicrosporidial stromal keratitis keratitis

Herpes simplex stromal keratitis Herpes simplex stromal keratitis

(n=10; 41.6%)(n=10; 41.6%)

Fungal keratitis (n = 7; 29.1%)Fungal keratitis (n = 7; 29.1%)

Bacterial keratitis (n = 3; 12.5%)Bacterial keratitis (n = 3; 12.5%)

Microsporidial keratitis (n = 4; 16.6%)Microsporidial keratitis (n = 4; 16.6%)

Clinical DiagnosisClinical Diagnosis

Microsporidial stromal Microsporidial stromal keratitiskeratitis

Microsporidial stromal Microsporidial stromal keratitiskeratitis

9 (37.5%) patients were treated as HSV keratitis 9 (37.5%) patients were treated as HSV keratitis after presentationafter presentation

Corneal scrapings (n = 9)Corneal scrapings (n = 9)

Histopathology Histopathology (n = 21)(n = 21)

Microsporidial stromal Microsporidial stromal keratitiskeratitis

Laboratory diagnosisLaboratory diagnosis

Duration between presentation and diagnosis Duration between presentation and diagnosis varied from 1 day to 3 yearsvaried from 1 day to 3 years

TopicalTopical

PHMB 0.02%PHMB 0.02%

Chlorhexidine 0.02%Chlorhexidine 0.02% Oral Oral

Albendazole Albendazole

KetoconazoleKetoconazole

Medical Treatment (n = 15)Medical Treatment (n = 15)

Microsporidial stromal Microsporidial stromal keratitiskeratitis

Results:Results:

PKP (n = 19)PKP (n = 19) Lamellar (n = 1) Lamellar (n = 1)

Surgical Treatment (n = 20)Surgical Treatment (n = 20)

Microsporidial stromal Microsporidial stromal keratitiskeratitis

Results:Results:

Can occur in any ageCan occur in any age

Slowly progressive disease with Slowly progressive disease with indolent courseindolent course

Initial clinical picture mimics HSV Initial clinical picture mimics HSV stromal keratitis.stromal keratitis.

Salient featuresSalient features

Microsporidial stromal Microsporidial stromal keratitiskeratitis

SummarySummary

High index of suspicion will help diagnosis of this High index of suspicion will help diagnosis of this rare disorderrare disorder