Introduction
An important cause of ocular morbidity as well as blindness in developing countries,
including India, is microbial keratitis. The incidence of microbial keratitis worldwide, ranges
from 6.3 to 710 cases per 100,000 population per year.1 Microorganisms, like bacteria,
viruses, fungi and parasites trigger an infective process, leading to severe corneal
inflammation, ulceration, scarring or even perforation, with devastating consequences.
Fungal or mycotic keratitis is a major cause of corneal blindness in tropical countries.
Fungi are usually taken as opportunistic agents of infection. They rarely infect the healthy,
intact cornea but in a compromised or immunosuppressed cornea, almost any fungal species
is capable of inducing infection. Moreover, widespread use of corticosteroids and broad-
spectrum antimicrobials has led to an increased incidence of fungal infections. In India, half
of all infectious corneal ulcers are fungal.2 In tropical countries, filamentous fungi are more
common, whereas yeast such as Candida is more prevalent in temperate climates. In recent
years, however, the rate of infection by filamentous fungi has increased. The clinical
presentation of fungal keratitis is non-specific and indolent and patients are initially treated
for bacterial, viral or even amoebic infections. Lack of appropriate therapy can lead to the
infection developing into an endophthalmitis and the eye can be lost forever. Alternatively,
the permanent scarring associated with delay in treatment can lead to significant loss of
vision.
Therefore, the major challenge in the management of fungal keratitis is the difficulty in
clinical and microbiological diagnosis. Although laboratory testing of corneal scrape
specimens remains the gold standard in the diagnosis of infectious keratitis, some organisms
are difficult to detect or culture in vitro and others are slow growing. Also corneal cultures are
positive only in 52.5-67% of cases.3 Further, the false-negative rate is another important
limitation in the diagnostic ability of corneal cultures.4 In such cases, delays in appropriate
treatment may occur.
Confocal microscopy is a non-invasive diagnostic modality for imaging the living
human cornea thereby it can provide its qualitative and quantitative analysis in healthy and
pathological states. Thus in vivo confocal microscopy (IVCM) can play a complementary role
in the early diagnosis of corneal infections and in monitoring the prognosis of the disease
1
process. Many published studies have shown confocal microscopy to be effective in the
diagnosis of Acanthamoeba5-7, fungal8-10, Nocardia11 and Microsporidia12 keratitis. A recent
study by Kanavi, et al in 133 microbial keratitis cases demonstrated that confocal microscopy
had sensitivity of 94% and specificity of 78% among patients with fungal keratitis.13
The rapidity of diagnosis, relative ease of use, and noninvasive nature of confocal
microscopy are clearly advantageous when compared to traditional laboratory techniques in
suspected cases of fungal keratitis. Hence the present study is being planned to determine if
confocal microscopy can provide a better and rapid method for diagnosing fungal keratitis
and thereby help in initiating appropriate and timely medical or surgical treatment.
2
Review of Literature
Fungi are a significant cause of microbial keratitis in warm and temperate climates (42-
46.8%).14,15 The most common microorganisms that cause fungal keratitis in tropical climates
are filamentous fungi i.e. Fusarium solani and other Fusarium species and Aspergillus
species. Whereas in temperate climates yeast such as Candida is more prevalent. Risk factors
for fungal keratitis include prior ocular injury with vegetative matter, long-term steroid use,
antimicrobial use, contact lens wear, contact lens solutions, chronic ocular surface disease,
and systemic immunosuppressive disorders.
The gold standard for making a diagnosis of fungal keratitis is the identification of
fungi on potassium hydroxide and/or calcofluor white wet mounts and isolation of fungus on
culture. Sabouraud dextrose agar (SDA) without cycloheximide and brain-heart infusion agar
is the preferred medium for isolation of fungal corneal pathogens. Making a diagnosis with
the help of cultures is difficult as fungi often take long time to grow and in any case, cultures
have low sensitivity, being positive in only about 60% of cases.16 Also, sometimes invasive
and potentially hazardous procedures like a corneal biopsy or anterior chamber paracentesis
may be required if there are deep-seated infiltrates within the corneal stroma. Antifungal
therapy depends upon the species of fungus involved. Filamentous fungi are sensitive to
topical natamycin drops while amphotericin B is used in candidial infections. Therefore,
patients with fungal keratitis are often started on an empirical therapy with broad-spectrum
antimicrobials or combination therapy because of delay in the definitive identification of the
causative organism.
Fungal Corneal Pathogens
Aspergillus hyphae are 3-6 μm in diameter and are septate with dichotomous branching
at an acute angle of about 45°. The conidiophore, with its swollen terminal end, surrounded
by flask-shaped sterigmata, each of which produces long chains of coccoid conidia that
radiate out from the terminal end, is highly diagnostic.17
In contrast, Fusarium species is characterized by distinctive macroconidia and
microconidia, with the main identifying morphologic feature being the falciform or crescent
or bean-shaped macroconidia. The final diagnosis relies on culture of organism from tissues
3
obtained at biopsy since histopathological examination cannot differentiate between
fusariosis and aspergillosis.17
Candida produces pseudohyphae and very rarely hyphae. The yeast cells are
approximately 4-8 µm with budding and pseudohyphae. The presence of pseudohayphae
shows colonization and tissue invasion hence their demonstration in the direct smear of tissue
is higly significant.17
Culture Characteristics
Colonies of Fusarium organisms are white in the early stages of development and as
they mature a variety of colour pigments are produced which are best seen on the
undersurface of the colony (reverse pigmentation).17 Aspergillus fumigatus colonies are
velvety or powdery at first but as spores are produced they become smoky green owing to the
pigmentation of the conidia. Colonies of A. niger are also white initially and turn dark brown
to black after sporulation.17 The typical colony of Candida organisms on SDA is cream
coloured, with a flat, round contour and pasty smooth consistency.17
During the last decade there has been a new surge in ocular diagnostic imaging
techniques. With exponential growth in technological innovation, the ability to make a rapid
and accurate diagnosis of ocular diseases has also enhanced. IVCM is a non-invasive
emerging technique that can be used for the study of corneal cellular structure. It has been
shown to be useful in diagnosing a range of pathogens thereby monitoring the treatment
response in microbial keratitis.
Confocal Microscope
Conventional light microscopy is hindered by reflection and diffraction of light from
structures surrounding the point of observation. This limits the resolution of slit-lamp bio
microscopy to only 20 µm and presence of oedema or scarring in the cornea further reduces
the clinical observation of cornea on slit lamp. To overcome these problems, confocal
microscope was developed by Marvin Minsky in 1955. The original confocal microscope was
used to image brain cells and study neural networks in the living brain.
The basic principle of a confocal microscope is that a single point of tissue can be
illuminated by a point source and simultaneously imaged by a camera in the same plane i.e. it
4
is confocal. In a confocal laser scanning microscope, a laser beam passes through a light
source aperture and then is focused by an objective lens into a small (ideally diffraction
limited) focal volume within or on the surface of a specimen producing an image with a very
high resolution but has a limited field of view. This makes it necessary to scan the focal point
across the sample rapidly and to reconstruct the image to allow a real-time on-screen view.18
Commercially available designs of confocal microscope include: Confoscan P4 (Tomey
Corporation, Cambridge, MA, USA), Confoscan 4 (Nidek Technologies, Japan) and
Heidelberg Retina Tomograph II (HRT II) Rostock Corneal Module (Heidelberg, Germany),
which is a laser confocal microscope.
The advantage of laser scanning confocal microscope is the ability to serially produce
images of thin layers from the cornea. According to this the depth of focus for the Tandem
scanning confocal microscope (TSCM ) is 7-9 μm and in slit scanning systems it is 26 μm
whilst it is 5-7 μm using the laser confocal microscope.
Clinical Applications of Confocal Microscope
As the corneal confocal microscopy is non-invasive technique for in vivo imaging of
the living cornea it can be used in the detection and management of pathologic and infectious
conditions, detection and management of corneal dystrophies and ectasias, monitoring
contact lens induced corneal changes, for pre- and post-surgical evaluation (PRK, LASIK and
LASEK, flap evaluations and Radial Keratotomy) and to monitor penetrating keratoplasty. Its
non-invasive nature could make it an important modality in the rapid diagnosis of fungal and
Acanthamoeba keratitis. It can be used to make repeated observations, which will aid in the
diagnosis, treatment and follow-up of cases of infectious keratitis.19
In 2006, a retrospective review of 63 patients with suspected Acanthamoeba keratitis
(AK) and undergoing tandem scanning confocal microscopy was published which showed
that in vivo TSCM successfully diagnosed 61 out of 63 cases, with 1 false-positive and 1
false-negative based on clinical data. It concluded that as compared to traditional laboratory
techniques IVCM is non-invasive, relatively easy to use and helps in rapid diagnosis. All this
leads to an improved visual outcome in AK.5
5
In a diagnostic test study, Kanavi, et al performed confocal scan and corneal and/or
contact lens case smear and culture in 133 eyes of 133 patients with a clinical diagnosis of
infectious keratitis at Labbafinejad Medical Center from 2004 to 2006. It concluded that the
sensitivity and specificity of confocal scans were 100% and 84% for the diagnosis of
acanthamoeba keratitis versus 94% and 78% for fungal keratitis, respectively. IVCM may
also be helpful in excluding fungal or acanthamoeba-like structures in cases with negative
bacteriological results and in early bacterial keratitis before clarification of microbiological
results.13
A study was done by Shi, et al to evaluate the role of IVCM in guiding antifungal
chemotherapy in patients with fungal keratitis. One hundred twenty one patients with fungal
keratitis were enrolled in this study and it was found that IVCM allowed comprehensive
evaluation of hyphae, inflammatory cells and corneal stromal cells in real time and provided
valuable and objective information required in selecting and adjusting therapeutic regimens
for the treatment of fungal keratitis.20
In another study, confocal images were selected for 62 eyes with culture- or biopsy
proven infections. The cases comprised 26 Acanthamoeba, 12 fungi, three Microsporidia,
two Nocardia and 19 bacterial infections (controls). The reference standard for comparison
was a positive tissue diagnosis. These images were assessed on two separate occasions by
four observers who were masked to the tissue diagnosis. The results showed moderate
sensitivity and moderate to high specificity values in diagnosing microbial keratitis with the
HRT II/RCM confocal microscope, higher diagnostic accuracy with clinicians experienced in
confocal microscopy and intra observer repeatability to be better than inter observer
reproducibility.21
Das, et al conducted a study at LV Prasad Eye Institute, India to assess the role of
IVCM in cases of fungal keratitis presenting with a deep stromal infiltrate. Six patients,
whose clinical presentation was characterized by deep stromal or multifocal endothelial
lesions, were subjected to in vivo confocal microscopy on the day of presentation. All the
patients underwent therapeutic penetrating keratoplasty. The excised corneal buttons were
bisected and subjected to microbiological and histopathological examinations. It was
concluded that confocal microscopy is a useful tool in diagnosis of cases of keratitis
presenting with deep stromal infiltrates.22
6
Review of recent literature on in vivo confocal microscopy and atypical microbial
keratitis was done in a study conducted in 2010, wherein they demonstrated that the use of
IVCM in the diagnosis of Acanthamoeba keratitis reduces the number of days to diagnosis,
expediting initiation of therapy and leading to excellent visual outcome. In case of fungal
keratitis confocal microscopy could be applied for monitoring and guidance of treatment and
to determine the depth of infection.23
Another study was done in 2010 to determine the effectiveness of laser confocal
microscopy in detecting filamentous fungi in the cornea of patients with fungal keratitis and
in evaluating the effectiveness of the treatment. The corneas of 6 patients clinically diagnosed
with fungal keratitis were examined with the HRT II-RCM. Three of these patients were also
monitored periodically with the HRT II-RCM after antifungal treatment. The results indicated
that HRT II-RCM can be used to diagnose and to monitor the effect of therapy on fungal
keratitis.24
In a recently concluded prospective, double masked, non-randomized, observational
clinical trial confocal microscopy and microbiology evaluation of 146 consecutive patients
with clinically suspected microbial keratitis was done. The study concluded that in addition to
the advantage of a rapid and early diagnosis, especially where slow-growing organisms like
fungi and Acanthamoeba are implicated, confocal microscopy could offer the advantage of
monitoring response to treatment through in vivo visualization of these organisms.25
However, a review of the existing literature shows that there is only limited published
data comparing the accuracy and usefulness of confocal microscopy in relation to other
diagnostic techniques, namely, microscopic examination of smears using various stains and
inoculation on various culture media and subsequent identification of growth using various
biochemical tests and morphological characteristics. Therefore, it has been planned to carry
out the present study to compare the diagnostic accuracy and efficacy of confocal microscope
with microbiological evaluation in the diagnosis of suspected fungal keratitis.
7
Aims and Objectives
1. To compare the role of in vivo confocal microscopy with conventional
microbiological evaluation for diagnosing suspected cases of fungal keratitis.
2. To find out the causative agents of fungal keratitis and their antifungal sensitivity
testing.
8
Materials and Methods
A prospective study, involving thirty eyes with clinically suspected fungal keratitis
presenting to the Cornea Clinic of Department of Ophthalmology, Government Medical
College Hospital, Chandigarh will be carried out in collaboration with the Department of
Microbiology..
Inclusion criteria
Minimum of thirty eyes with clinically suspected fungal keratitis will be included.
Exclusion criteria
Children where confocal microscopy or microbiological examination is not possible.
Patients refusing confocal microscopy or microbiological examination.
Poor image quality of confocal scans despite repeated attempts.
Informed consent will be taken from all the patients for their inclusion in the study.
The clinical examination of each patient will be done including a detailed history as
regards to age, sex, duration and severity of symptoms, history of trauma or contact lens use
or prolonged intake of steroids and if any previous treatment has been taken and its type.
History regarding any diagnosed systemic illness and treatment will also be taken.
Uncorrected and best-corrected Snellen visual acuity will be recorded for all patients.
Detailed slit-lamp examination including size and depth of ulcer, extent of infiltrates, scleral
involvement, size of hypopyon and conjunctival and corneal vascularisation, will be done.26
Determination of intraocular pressure measurement with Goldmann applanation tonometry
(wherever possible) and clinical photography to document corneal findings will also be
performed.
The confocal microscopy examination will be done with a commercially available slit
scanning confocal microscope, Confoscan 4 (NIDEK Technologies, Freemont, CA); using a
Zeiss Achroplan 40/0.75 W lens in the manual scan mode and customized software for image
analysis (NAVIS). The light intensity of the scan will be 128 units to begin with and will vary
dynamically during the procedure based on the amount of illumination required. The lens will
be sterilized in 70% isopropyl alcohol before and after each examination. The eye to be
examined will be held open by a similarly sterilized Barraquer wire speculum after
9
instillation of 0.5% proparacaine topical anesthesia drops. Polyacrylic acid 0.2% (Viscotirs
Gel, CIBA Vision, Atlanta, GA) will be used as the coupling gel. In all cases, the scan will be
done before corneal scrapings are taken for microbiologic examination. The confocal
scanning will be performed in 4 quadrants and the images will be analyzed to identify cellular
details and evidence of fungal filaments. A diagnosis of either fungal keratitis or no
organisms will be documented. All cases will be subjected to corneal scrapings after confocal
microscopy. The microbiologist evaluating the smears and cultures will be masked from the
confocal findings.
All cases will undergo corneal scrapings from base and margins of the ulcer with a
disposable no. 15 Bard Parker blade under topical anaesthesia (4% xylocaine drops) under
aseptic conditions. The material will then be plated on two glass slides for Gram’s staining
and KOH wet mount and would be examined under microscope using high power
magnification. The material from the corneal scrapings will also be directly inoculated on
blood agar and brain heart infusion (BHI) agar and incubated at 25ºC and 37ºC. Two sets of
Sabouraud dextrose agar containing antibiotics but without actidione will also be inoculated
and incubated at 25ºC and 37ºC, separately. The corneal scrapings will be inoculated on agar
plates in a ‘C’ or ‘S’ -shaped streak. All media would be incubated for 4 weeks and would be
checked everyday during first week and twice a week during next three weeks.17 All the
smears and cultures will be evaluated by a microbiologist. Cases will be defined as all those
in which fungal filaments will be identified on any one or more smear examination methods
(KOH/Gram) or showed significant growth in culture.
10
Statistical Analysis
The normality of the measurable data like age, visual acuity, size of ulcer, etc. will be assessed using Kolmogorov-Smirnov Test. Comparisons will be performed using Mann-Whitney U Test and Student t-test for normally distributed data and skewed data respectively. The association of various categorical/classified data will be analyzed using Chi-square Test or Fisher’s exact test whichever is applicable. The normally distributed data will be expressed as mean , standard deviation, range etc. whereas skewed data will be expressed as median and inter quartile range. The categorical data will be expressed as frequencies, percentages etc.
The data will also be depicted graphically using histograms, bar diagrams and pie charts.
11
Ethical Considerations
All the procedures, which will be carried out in the present study, are routinely required
and performed in the Department of Ophthalmology, GMCH, Chandigarh. This study will
not render the subject to additional risk. It will be conducted on the ethical guidelines for
biomedical research on human subjects as given by Central Ethics Committee on Human
Research (CEHER ), ICMR, New Delhi,2006.and in the tenets of “Declaration of
Helsinki”,2008.
12
Information to the patient
Purpose of Research
Fungal keratitis is an important cause of ocular morbidity in developing countries. The
purpose of this study is to see if confocal microscope can provide a means for early and
accurate diagnosis of fungal keratitis and thereby prevent delay in starting of appropriate
treatment.
Study Procedure
A detailed ophthalmological examination will be done including visual acuity and confocal
microscopy. Corneal scrapings will be sent for microbiological examination.
Confidentiality
Your medical records will be treated with utmost confidentiality and will be revealed only to
other doctors/scientists involved with this study. The results of this study would be published
in scientific journals/thesis but you will not be identified by name.
Your participation and rights
Your participation in the study is absolutely voluntary and you may withdraw from the study
any time without having to give reasons for the same. In any case, you will receive
appropriate treatment for your condition under routine services at GMCH, Chandigarh.
13
Patient Informed Consent Form
Patient identification number for this trial : __________________
Title of project : Confocal microscopy versus microbiological evaluation in diagnosing suspected fungal keratitis
Name of Principal Investigator : _______________________ Tel. No. _______________
The contents of the information sheet dated ____________ (version) ________that was provided have been read carefully by me / explained in detail to me, in a language that I comprehend, and I have fully understood the contents. I confirm that I have had the opportunity to ask questions.
The nature and purpose of the study and its potential risks/ benefits and expected duration of the study, and other relevant details of the study have been explained to me in detail. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason, without my medical care or legal right being affected.
I understand that the information collected about me from my participation in this research and sections of any of my medical notes may be looked at by responsible individuals. I give permission to these individuals to have access to my records.
I agree to take part in the above study.
Date:
………………………………………………….. Place:
(Signature/Left Thumb impression)
Name of the participant : ____________________________
Son/Daughter/Spouse of : ____________________________
Complete address : _______________________________________
This is to certify that the above consent has been obtained in my presence.
……………………….. Date :
Signature of the Principal Investigator Place :
Mobile:
1) Witness - 1 2) Witness - 2
…………………… ……………………….
(Signature/thumb impression) (Signature/thumb impression)
Name : ___________________ Name : __________________
14
Address : _________________ Address : _________________
15
References
1. Thomas PA, Geraldine P. Infectious keratitis. Curr Opin Infect Dis 2007; 20: 129-41.
2. Loh A, Hong K, Lee S, Mannis M, Acharya N. Practice patterns in the management of
fungal corneal ulcers. Cornea 2009; 28: 856-59.
3. Erie J, McLaren J, Patel S. Confocal microscopy in ophthalmology. Am J Ophthalmol
2009; 148: 639-46.
4. Keay L, Edwards K, Naduvilath T, Taylor HR, Snibson GR, Forde K, et al. Microbial
keratitis predisposing factors and morbidity. Ophthalmology 2006; 113: 109-16.
5. Parmar DN, Awwad ST, Petroll WM, Bowman RW, McCulley JP, Cavanagh HD, et al.
Tandem scanning confocal corneal microscopy in the diagnosis of suspected
acanthamoeba keratitis. Ophthalmology 2006; 113: 538-47.
6. Matsumoto Y, Dogru M, Sato E, Katono Y, Uchino Y, Schimmura S, et al. The
application of in vivo confocal scanning laser microscopy in the management of
acanthamoeba keratitis. Mol Vis 2007; 13: 1319-26.
7. Kobayashi A, Ishibashi Y, Oikawa Y, Yokogawa H, Sugiyama K, et al. In vivo and ex
vivo laser confocal microscopy findings in patients with early-stage Acanthamoeba
keratitis. Cornea 2008; 27: 439-45.
8. Avunduk AM, Beuerman RW, Varnell ED, Kaufman HE. Confocal microscopy of
Aspergillus fumigatus keratitis. Br J Ophthalmol 2003; 87: 409-10.
9. Brasnu E, Bourcier T, Dupas B, Degorge S, Rodallec T, Laroche L, et al. In vivo
confocal microscopy in fungal keratitis. Br J Ophthalmol 2007; 91: 588-91.
10. Tu EY, Park AJ. Recalcitrant Beauveria bassiana keratitis: confocal microscopy
findings and treatment with posaconazole (Noxafil). Cornea 2007; 26: 1008-10.
11. Vaddavalli PK, Garg P, Sharma S, Thomas R, Rao GN, et al. Confocal microscopy for
Nocardia keratitis. Ophthalmology 2006; 113: 1645-50.
12. Sagoo MS, Mehta JS, Hau S, Irion LD, Curry A, Bonshek R, et al. Microsporidium
stromal keratitis: in vivo confocal findings. Cornea 2007; 26: 870-73.
13. Kanavi MR, Javadi M, Yazdani S, Mirdehghanm S. Sensitivity and specificity of
confocal scan in the diagnosis of infectious keratitis. Cornea 2007; 26: 782-86.
14. 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.
16
15. Leck AK, Thomas PA, Hagan M, Kaliamurthy J, Ackuaku E, John M, et al. Aetiology
of suppurative corneal ulcers in Ghana and south India and epidemiology of fungal
keratitis. Br J Ophthalmol 2002; 86: 1211-15.
16. Yeh DL, Stinnett SS, Afshari NA. Analysis of bacterial cultures in infectious keratitis.
Am J Ophthalmol 2006; 142; 1066-68.
17. Chander J, Textbook of Medical Mycology. 2009; 3rd edn. Mehta Publishers, New
Delhi.
18. Kaufman SC, Musch DC, Belin MW, Cohen EJ, Meisler DM, Reinhart WJ, et al.
Ophthalmic technology assessment committee cornea panel. Confocal microscopy: a
report by the American Academy of Ophthalmology. Ophthalmology 2004; 111: 396-
406.
19. O’Day DM, Head WS. Advances in the management of keratomycosis and
Acanthamoeba keratitis. Cornea 2000; 19: 681-7.
20. Shi W, Li S, Liu M, Jin H, Xie L. Antifungal chemotherapy for fungal keratitis guided
by in vivo confocal microscopy. Graefes Arch Clin Exp Ophthalmol 2008; 246: 581-6.
21. Hau SC, Dart JKG, Vesaluoma M, Parmar DN, Claerhout I, Bibi K, et al. Diagnostic
accuracy of microbial keratitis with in vivo scanning laser confocal microscopy. Br J
Ophthalmol 2010; 94: 982-87.
22. Das S, Samant M, Garg P, Vaddavalli PK, Vemuganti GK. Role of confocal
microscopy in deep fungal keratitis. Cornea 2009; 28: 11-13.
23. Kumar RL, Cruzat A, Hamrah P. Current state of in vivo confocal microscopy in
management of microbial keratitis. Seminars in Ophthalmology 2010; 25: 166-70.
24. Takezawa Y, Shiraishi A, Noda E, Hara Y, Yamaguchi M, Uno T, Ohashi Y.
Effectiveness of in vivo confocal microscopy in detecting filamentous fungi during
clinical course of fungal keratitis. Cornea 2010; 29: 1346-52.
25. Vaddavalli PK, Garg P, Sharma S, Sangwan VS, Rao GN, Thomas R. Role of confocal
microscopy in the diagnosis of fungal and Acanthamoeba keratitis. Ophthalmology
2011; 118: 29-35.
26. Arya SK, Aggarwal M, Chander J, Sonika S, Sood S. Comparative evaluation of
amniotic membrane transplantation with conventional medical treatment versus
conventional medical treatment alone in suppurative keratitis . The Internet Journal of
Ophthalmology and Visual Science 2009; 6(2).
17
Proforma
Serial number. DateName Age/Sex
CR No./Admn No. AddressCornea clinic No. Phone No.
Symptoms Grades Duration
Decreased vision 0 1 2 3 4 5
Pain 0 1 2 3 4 5
Redness 0 1 2 3 4 5
Photophobia 0 1 2 3 4 5
Watering & Discharge 0 1 2 3 4 5
Any other complaints : _______________________________________________________History of any trauma : ______________________________History of contact lens use : _____________________________ History of any ocular surgery : ___________________________
TREATMENT HISTORY
1. Antibiotics Yes / No2. Antifungals Yes / No3. Corticosteroids Yes / No4. Others Yes / No
SYSTEMIC HISTORY DurationDiabetes Mellitus Yes / No __________Hypertension Yes / No __________Others Yes / No __________
GENERAL PHYSICAL EXAMINATION
Built: Pulse: BP :Temp: Anaemia:
SYSTEMIC EXAMINATION
CVS RSCNS ABDO
18
OCULAR EXAMINATION
Visual Acuity Right Eye Left EyeV/A Power V/A Power
Distance UnaidedAided
Near UnaidedAided
RIGHT EYE LEFT EYE1) Eye lids2) Eye balls
a) Positionb) Visual axisc) Movements
3) Lacrimal apparatus
SLIT LAMP EXAMINATION
1) Conjunctivaa) Dischargeb) Congestionc) Papillae
2) Sclera3) Cornea
a) Sizeb) Shapec) Surfaced) Vascularisatione) Sensationsf) Transparency
4) Characteristics of ulcera) Site of ulcerb) Size of ulcerc) Shape of ulcerd) Depth of ulcer(%)e) Floor & edgesf) Infiltrate
5) Grade of ulcera) Mildb) Moderatec) Severe
6) Anterior chambera) Depthb) AC contents
i) Aqueous flareii) Aqueous cells
19
iii) Hypopyon7) Iris
a) Colourb) Patternc) Synechiae
8) Pupila) Sizeb) Shapec) Locationd) Reaction to light
9) Intraocular lens10) Fundus11) Intraocular pressure
Clinical Diagnosis : R/E _________________________ L/E _____________________
INVESTIGATIONS
1) Fluoroscein staining :2) Scraping smear
a) Gram stainb) KOH wet mountc) Culture sensitivity
i) Bacterialii) Fungal
3) Findings of confocal microscopy :
FINAL DIAGNOSIS : ___________________________________________
Medical treatment :
Surgical treatment :Day 1
Vision (u.a.) 0 1 2 3 4 5Aided vision 0 1 2 3 4 5SymptomsPain 0 1 2 3 4 5Redness 0 1 2 3 4 5Photophobia 0 1 2 3 4 5W & D 0 1 2 3 4 5SignsConjunctiva 0 1 2 3 4 5Corneal oedema 0 1 2 3 4 5
20
Corneal vascularisation 0 1 2 3 4 5Size of ulcer 0 1 2 3 4 5Depth of ulcer (%) 0 1 2 3 4 5Infiltrate 0 1 2 3 4 5Extent of edge (sclera involvement) 0 1 2 3 4 5Hypopyon 0 1 2 3 4 5AC reaction 0 1 2 3 4 5Complications if any
Grading of Signs & Symptoms
1) VISION : Grade 0 - Normal Grade 1 -6/6 - 6/18 Grade 2 - 6/24 -6/60 Grade 3 - <6/60 – 3/60
Grade 4 -<3/60
2) PAIN : Grade 0 - No pain Grade 1 - Occassional mild pain Grade 2 - Constant mild pain Grade 3 - Moderate to severe pain Grade 4 - Constant severe pain
3) REDNESS : Grade 0 - No redness Grade 1 - redness in 1 quadrant Grade 2 - redness in 2 quadrants Grade 3 - redness in 4 quadrants Grade 4 - redness all around
4) PHOTOPHOBIA : Grade 0 - No photophobia Grade 1 - Photophobia only in bright light Grade 2 - Photophobia in day light Grade 3 - Photophobia in dim light Grade 4 - Photophobia without light
5) WATERING & DISCHARGE : Grade 0 - No watering or discharge Grade 1 - Only watering Grade 2 - Occasional discharge Grade 3 - Constant discharge Grade 4 - Foul smelling constant discharge
6) CONJUNCTIVA : Grade 0 - Normal Grade 1 - 1 quadrant congested Grade 2 - 2 quadrants congested Grade 3 - 3 quadrants congested Grade 5 - Congestion all around
7) CORNEAL OEDEMA : Grade 0 - Only in ulcer area Grade 1 - Beyond ulcer area Grade 2 - Involving ½ of cornea Grade 3 - Involving whole of cornea but iris can be seen Grade 4 - Whole of cornea involved and no iris detail seen
8) CORNEAL VASCULARISATION : Grade 0 - No vascularisation Grade 1 - Superficial corneal vascularisation 1-5clock hours Grade 2 - Superficial corneal vascularisation >5 clock hours
21
Grade 3 - Deep vascularisation Grade 4 - Extensive superficial & deep vascularisation
9) SIZE OF ULCER : Grade 0 - <0.5 mm Grade 1 - 0.5 – 1 mmGrade 2 - > 1-2 mm Grade 3- > 2 – 5 mmGrade 4 - > 5mm
10) DEPTH OF ULCER : Grade 0 - Epithelium normal Grade 1- Only Epithelium involved Grade 2 - <20% of stroma involved Grade 3 - 20-50 % of stroma involved Grade 4 - > 50 % of stroma involved
11) INFILTRATE : Grade 0 - No infiltrateGrade 1 - Only upto epithelial surfaceGrade 2 - Infiltate may be dense but superficial and limited to ulcer baseGrade 3 - Infiltrate dense extending upto mid stromaGrade 4 - Infiltrate dense extending deeper than mid stroma or into Sclera
12) HYPOPYON : Grade 0 - No hypopyon Grade 1 - Upto 1 mm Grade 2 - > 1-2 mm Grade 3 - > 2-3 mm Grade 4 - > 3mm
13) AC REACTION : Grade 0 - <5 cells Grade 1 - 5–10 cells Grade 2 - 11-20 cells Grade 3 - 21-50 cells Grade 4 - > 50 cells
22
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