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103]

Original Article

Causative fungi and treatment outcome of dematiaceous fungal keratitis in

North India

Ajit Kumar, Ashi Khurana, Mohit Sharma1, Lokesh Chauhan2

Purpose: The aim of the study is to identify risk factors, clinical characteristics, causative fungi, and Access this article online
treatment outcome of dematiaceous fungal keratitis in North India. Methods: Consecutive cases of Website:
culture‑proven dematiaceous fungal keratitis between January 2012 and June 2017 were retrieved from the www.ijo.in
medical record department. Risk factors, clinical signs, and outcome were registered. Results: Eighty‑three DOI:
patients were included. Identified dematiaceous fungal organism were Curvularia sp. (n = 55/83; 66.3%), 10.4103/ijo.IJO_1612_18
Alternaria sp. (n = 12/83; 14.5%), Ulocladium sp. (n = 5/83; 6%), Bipolaris sp. (n = 5/83; 6.1%), Scedosporium PMID:
*****
sp. (n = 3/83; 3.6%), Acremonium sp. (n = 2/83; 2.4%), and Epicoccum sp. (n = 1/83; 1.2%). Male preponderance
was reported. The most common predisposing factor was corneal trauma (67.4%). In cases associated with Quick Response Code:
corneal trauma due to vegetative matter, sugarcane was the most common cause. In all, 89% of the patients
were more than 30 years of age. The median infiltrate size was 8 mm2. The median time of antifungal
therapy was 4.2 weeks (interquartile range [IQR]: 1‑25 weeks). Complications were seen in 14 (n = 14/65;
21.5%) patients. Complete resolution of dematiaceous fungal keratitis was present in 27 (n = 27/65; 41.5%)
eyes. Conclusion: Curvularia sp. and Alternaria sp. were the predominant pathogenic genera causing
dematiaceous fungal keratitis. Among the causative fungi, infections due to Scedosporium sp. were associated
with the worst outcomes. Ulocladium sp. and Epicoccum sp. were also identified. Both the species are not
reported previously as a causal organism of dematiaceous fungal keratitis from North India.

Key words: Alternaria, Curvularia, dematiaceous fungi, Epicoccum, keratitis, Ulocladium, Uttar Pradesh

Fungal keratitis is more virulent and damaging than bacterial dematiaceous fungal keratitis has been reported mostly in
keratitis.[1] Ocular trauma by vegetative matter, topical steroid case report. There are few case series published from India,[11,16]
use, and use of contact lens are the associated risk factors of and United States[17] on outcome of dematiaceous fungal
fungal keratitis. It is more common in males, compared with keratitis. These studies were published more than a decade
females. Previous studies from India reported that 34% to 44% ago. There were no reports available about recent pattern
of all keratitis were caused by fungi.[2‑7] In tropical countries, and outcome of dematiaceous fungal keratitis during last
8% to 17% of the keratitis are caused by dematiaceous fungi.[8] 5 years. The epidemiological pattern and causative agents for
Dematiaceous fungi are uncommon but important cause of dematiaceous fungal keratitis can vary significantly from region
human disease. Over 100 species of dematiaceous fungi have to region within a country. Knowledge of common fungal
been identified causing infections in human beings.[9] Alternaria isolates in a region is important for management of fungal
sp., Bipolaris sp., Curvularia sp., Exophiala sp., Madurella sp., keratitis. A regular reporting of fungal isolates is necessary
Phialophora sp., Scedosporium prolificans, Fonsecaea pedrosoi, for identification of any new pattern. The objective of this
Cladophialophora bantiana, Scytalidium dimidiatum, and study was to report clinical characteristics, microbiological
Wangiella dermatitidis are the commonest pigmented fungal characteristics, and treatment outcome of dematiaceous fungal
species causing infections in humans.[10] These fungi are keratitis in North India.
distributed worldwide especially in tropics including India.[11‑14]
Dematiaceous fungi are found in soil and decomposing Methods
plant material. The characteristic dark color of their spores
and hyphae is because of presence of melanin in their cell This is a retrospective, noncomparative, observational
wall. Macroscopic and microscopic pigmentation of corneal case series. The study was approved by institutional ethics
infiltrates in the form of raised plaques is a characteristic of committee and adhered to the principles of the Declaration
dematiaceous fungal keratitis.[15] of Helsinki. Clinical records of all consecutive patients with
culture proven diagnosis of dematiaceous fungal keratitis, who
The outcome of non‑pigmented fungal keratitis has
been extensively reported. [2‑7] However, the outcome of This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License,
Departments of Cornea and Refractive Error, 1 Microbiology, which allows others to remix, tweak, and build upon the work non-commercially,
as long as appropriate credit is given and the new creations are licensed under
and 2Clinical Research, C L Gupta Eye Institute, Ram Ganga Vihar,
the identical terms.
Phase 2(Ext) Moradabad, Uttar Pradesh, India
Correspondence to: Dr. Ajit Kumar, Department of Cornea and For reprints contact: [email protected]
Refractive Error, C L Gupta Eye Institute, Ram Ganga Vihar,
Phase 2(Ext) Moradabad ‑ 244 001, Uttar Pradesh, India. Cite this article as: Kumar A, Khurana A, Sharma M, Chauhan L. Causative
E‑mail: [email protected] fungi and treatment outcome of dematiaceous fungal keratitis in North India.
Indian J Ophthalmol 2019;67:1048-53.
Manuscript received: 24.09.18; Revision accepted: 07.02.19

© 2019 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

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July 2019 Kumar, et al.: Dematiaceous fungal keratitis in North India 1049

presented to the cornea services, from January 2012 to June Results

2017 were included. Diagnosis of dematiaceous fungal keratitis
was made on the basis of microbiological investigations and A total of 83 patients were found eligible for the study. In
clinical findings such as corneal epithelial defect, stromal all, 57.8% (n = 48) of them were male, and 42.2% (n = 35)
infiltrate, and raised pigmented plaque. Patients with evidence of them were female. The median age of all patients was
of keratitis due to non‑pigmented fungi, bacteria, Herpes 45 years (interquartile range [IQR]: 35‑55 years). Average
simplex virus, and Acanthamoeba species were excluded from age of male patients was 45.3 ± 15.1 years, and of female
this study. patients was 44.7 ± 12.8 years (P = 0.84, independent t test).
Left eye was involved in 43 (n = 43/83; 51.8%) patients, and
A detailed examination of both eyes was performed using right eye was involved in 40 (n = 40/83; 48.2%) patients. In all,
the slit‑lamp biomicroscope. Standard case report form 66.2% (n = 55/83) patients with dematiaceous fungal keratitis
was developed to capture details of each patient including were presented from September to December [Fig. 1]. Monthly
socio‑demographic information clinical finding, predisposing distribution of culture proven dematiaceous fungal keratitis
factors, history of corneal trauma, nature of agent causing patients reported to our cornea clinic was presented in Table 1.
trauma, associated ocular conditions, other systemic diseases,
use of steroid eye drop, therapy received prior to presentation, Corneal trauma was sustained in 67.4% (n = 56/83) of
and visual acuity at the time of presentation. Symptoms and participants prior to onset of the ulcer. The most common
size of epithelial defect, with or without hypopyon, and cause of trauma was vegetative matter in 32 of these
infiltrate as measured by the variable slit on the biomicroscope 56 (56.1%) patients. In all, 53.1% (n = 17/32) of the injuries
were also recorded. due to vegetative matter were caused by sugarcane. Wood
stick injury (n = 8/24; 33.3%) and insects (n = 4/24; 16.4%)
Corneal ulceration was defined as a loss of the corneal were the main non‑vegetative cause of trauma [Table 2].
epithelium with underlying stromal infiltration and Three patients (n = 3/83; 3.6%) were using topical steroids
suppuration associated with signs of inflammation with or at the time of presentation. Systemic illness was present in
without hypopyon.[2] Corneal scrapings were obtained from 12 (n = 12/83; 14.5%) patients. Concurrent systemic diseases
the base and edge of the ulcer using a sterile surgical blade were hypertension (n = 5/83; 6%), diabetes (n = 3/83; 3.6%),
(# 15 on a Bard Parker handle) under topical anesthesia asthma (n = 2/83; 2.4%), coronary artery disease (n = 1/83; 1.2%),
(0.5% proparacaine hydrochloride) and slit‑lamp magnification. thyroid (n = 1/83; 1.2%), and arteritis (n = 1/83; 1.2%). History of
Gram stain and 10% potassium hydroxide mount were included prior medication was present in 60 (n = 60/83; 72.3%) patients;
as a part of the standard protocol for microscopic evaluation of 32 (n = 32/83; 38.6%) of them were using topical antibiotics.
corneal smears. Gram‑stained smears were examined at ×400 Remaining 28 (n = 28/60; 46.7%) patients did not remember
and ×1000 magnification, and the potassium hydroxide (KOH) the name of medication they were using.
preparations were examined at ×200 and ×400 magnification
Ocular comorbidities were present in four (4.8%) eyes.
under light microscope. Scrapings for smears were collected
The cornea was totally melted in seven (8.4%) patients. In the
prior to those for culture.
remaining 76 patients, the median infiltrate size was 8 mm2
For culture, the material was inoculated on to chocolate (IQR: 2.0–17 mm2). Hypopyon was present in 14 (n = 14/83;
agar, blood agar, sabouraud dextrose agar (SDA), brain 16.4%) patients. The mean infiltrate size in eyes with hypopyon
heart infusion, and thioglycolate and incubated at 25°C and was 15.2 ± 7.5 mm2, as compared to 8.8 ± 8.7 mm2 in eyes without
37°C. Cultures were examined daily during first week, twice hypopyon (P = 0.012, independent t test). Fifteen (n = 15/83;
weekly for next 3 weeks, and discarded after 3 to 4 weeks if 18.1%) patients were presented with pigmented, raised,
there was no growth. Dematiaceous fungi were identified by plaque‑like infiltrate. The presenting visual acuity in affected
their colony characteristics on SDA and by the morphological eye was more than 20/30 in 20 (n = 20/83; 24.1%) eyes, from
appearance of the spores in lactophenol cotton blue stain and, 20/30 to 20/60 in 12 (n = 12/83; 14.5%) eyes, less than 20/60 to
in some cases, by slide culture method. All laboratory methods 20/200 in 14 (n = 14/83; 16.8%) eyes, and less than 20/200 in
were performed under standard protocol, which have been 37 (n = 37/83; 44.5%) eyes.
discussed in detail in the previous studies.[1,2,11‑14] An isolate
Only fungal infection was reported in 73 (n = 73/83; 87.9%)
was considered dematiaceous if fungal colonies revealed black
patients, and mixed bacterial/fungal infection was reported in
or brown pigmentation, and lactophenol cotton blue mount
from the culture revealed black or brown pigmented hyphae,
conidia, or both.
The eyes were treated initially based on the clinical
evaluation and microbiological smear examinations. The eyes
were treated with 5% natamycin suspension on an hourly
basis. Topical voriconazole 1% (Vozole, Aurolab, India) was
supplemented for larger and deeper fungal ulcers.
Statistical analysis
The statistical analysis was performed with SPSS 17.0
software (SPSS Inc, Chicago, IL, USA). Descriptive statistics
were obtained to determine the frequency and proportions.
Mean and standard deviation were calculated for continuous Figure 1: Monthly trend of culture proven dematiaceous keratitis
variables. patients presented to cornea clinic
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1050 Indian Journal of Ophthalmology Volume 67 Issue 7

Table 1: Month wise distribution of dematiaceous fungal keratitis

ORGANISM Month Total

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Curvularia sp. 1 3 2 1 × × 2 1 12 19 14 × 55
Alternaria sp. × 2 × 2 × 1 1 × × × 5 1 12
Ulocladium sp. × 1 × × × 1 2 × × × 1 × 5
Bipolaris sp. 1 × × 2 × 1 × × × × 1 × 5
Scedosporium sp. × 1 × × × 1 × × × × 1 × 3
Acremonium sp. × × × × × × × × × 2 × × 2
Epicoccum sp. × × × 1 × × × × × × × × 1
Total 2 7 2 6 × 4 5 1 12 21 22 1 83

Table 2: Nature of trauma

Visual acuity at last follow‑up was recorded in
53 (n = 53/65; 81.5%) patients. Of them, visual acuity was
Nature of trauma Number Frequency improved or remain unchanged in 44 (n = 44/53; 83%) patients,
Sugarcane 17 30.4% and decreased in 9 (n = 9/53; 17%) patients. As shown in Table 4,
there was a statistically significant difference (P = 0.00; Fisher’s
Plant leaf 13 23.2%
exact test) between presenting and final visual acuity. Final
Wood 8 14.3%
visual acuity was recorded in six patients (out of 10) with
Dust 5 8.9% mixed infection. Of them, four (n = 4/6; 66.7%) had final visual
Insect 4 7.1% acuity between 20/30 and 20/60, and two (n = 2/6; 33.3%) had
Paddy 2 3.6% final visual acuity worse than 20/200. There was no statistically
Bed sheet 1 1.8% significant difference (P = 0.083; Fisher’s exact test) in final
Buffalo tail 1 1.8% visual acuity between mono and mixed infection. The results
Finger 1 1.8%
are summarized in Table 5.
Hand 1 1.8% Discussion
Powder 1 1.8%
Soap 1 1.8%
The prevalence of fungal keratitis among all corneal ulcer has
Stone 1 1.8%
been increasing in India. Srinivasan et al.[2] in 1997 reported 32%
fungal keratitis, and Tilak et al.[7] in 2010 reported 45.5% fungal
keratitis among all microbial keratitis. Most of the patients with
10 (n = 10/83; 12.1%) patients. Among fungal infections, the most dematiaceous fungal keratitis were presented in the month of
frequently identified fungi was Curvularia sp. (n = 55/83; 66.3%). September, October, and November. These months correspond
Other fungal organisms were Alternaria sp. (n = 12/83; 14.5%), to the harvesting season in the study area. The average age of
Ulocladium sp. (n = 5/83; 6%), Bipolaris sp. (n = 5/83; 6%), patients (45.1 years) in this study was consistent with multiple
Scedosporium sp. (n = 3/83; 3.6%), Acremonium sp. (n = 2/83; 2.4%), reported from South India.[11,16,18,19] Age of patients in this study
and Epicoccum sp. (n = 1/83; 1.2%) [Table 3]. In 10 patients with ranged from 11 to 80 years; however, in a study by Garg et al.,[11]
mixed infection, fungal isolates were Curvularia sp. (n = 4), patients age ranged from 1 to 75 years. In this study, none of
Alternaria sp. (n = 3), Bipolaris sp. (n = 2), and Ulocladium the patients belong to newborns, infants, and preschool age
sp. (n = 1). Bacterial isolates in these patients were Staphylococcus group. Majority of patients were more than 30 years of age.
sp. (n = 5), Streptococcus sp. (n = 1), Acinetobacter (n = 1), This suggests that working individuals are more affected from
Corynebacterium (n = 1), and Pseudomonas sp. (n = 2). dematiaceous fungal keratitis in the study area. In this study,
male preponderance was reported, which is consistent with
Eighteen (n = 18/83; 21.7%) patients did not present
the previous studies.[11,16,18]
for follow‑up after initiation of antifungal therapy. For
the rest (n = 65), median time of antifungal therapy was In this study, corneal injury with vegetative matter
4.2 weeks (IQR: 1‑25 weeks). Complications were seen in predisposing to corneal infection was found to be similar with
14 (14/65; 21.5%) patients. Corneal thinning was present in previous studies.[2‑4,11] The vegetative nature of trauma was the
eight (8/65; 12.3%) eyes, corneal perforation in four (4/65; 6.1%) most frequent risk factor identified. Among vegetative matter,
eyes, descemetocele in one (1/65; 1.5%) eye, and iris prolapse sugarcane was the most frequent cause of corneal trauma. This
in one (1/65; 1.5%) eye. Tissue adhesive and bandage is due to the geographic location of the patient population,
contact lens (TA + BCL) was applied in four (4/65; 6.1%) which is Uttar Pradesh, the highest sugarcane producing state
eyes, therapeutic penetrating keratoplasty was performed of India. The tall leaves of sugarcane plant being closure to
in four (4/65; 6.1%) eyes, and evisceration was done in two eye level is the main reason of corneal injury due to sugarcane
(2/65; 3.1%) eyes. Resolution of stromal infiltrate with corneal plant. Wearing contact lens was not identified as a predisposing
scarring was seen in 52 (52/65; 80%) patients. The median time factor in this series. This result is consistent with other studies
of scar appearance was 7 days (IQR: 6‑10.5 days). Complete reported from India.[2‑4,11] This may be explained by less
resolution of dematiaceous fungal keratitis was present in popularity of contact lens due to its cost, or unavailability of
27 (n = 27/65; 41.5%) eyes. contact lens services in rural North India.
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July 2019 Kumar, et al.: Dematiaceous fungal keratitis in North India 1051

Table 3: Comparison of previous studies on dematiaceous fungal keratitis with the present study
Dematiaceous fungal isolate Sengupta et al., 2010 Garg et al., 1999 Kumar et al., 2018 Present Study
Curvularia 84 (72%) 20 (22.7%) 55 (66.3%)
Bipolaris and Exserohilum 8 (6.8%) 13 (14.7%) 5 (6.1%)
Lasiodiplodia 0 (0%) 3 (3.4%) 0 (0%)
Torula 0 (0%) 3 (3.4%) 0 (0%)
Alternaria 4 (3.4%) 2 (2.2%) 12 (14.5%)
Humicola 0 (0%) 2 (2.2%) 0 (0%)
Aureobasidium 0 (0%) 2 (2.2%) 0 (0%)
Ulocladium 0 (0%) 0 (0%) 5 (6%)
Scedosporium 0 (0%) 0 (0%) 3 (3.6%)
Acremonium 0 (0%) 0 (0%) 2 (2.4%)
Epicoccum 0 (0%) 0 (0%) 1 (1.2%)

Table 4: Cross‑tabulation of presenting VA and final VA (n=53)

Presenting VA VA at last follow‑up Total

>20/30 <20/30 to 20/60 <20/60 to 20/200 <20/200

>20/30 14 0 0 0 14
<20/30 to 20/60 3 2 1 1 7
<20/60 to 20/200 2 5 1 3 11
<20/200 1 4 5 11 21
Total 20 11 7 15 53
Value Degree of freedom Significance (2‑sided)
Pearson Chi‑square 40.510a 9 0.00
Likelihood ratio 46.679 9 0.00
Fisher’s exact test 38.561 0.00
a
13 cells (81.2%) have expected count <5

Table 5: Distribution of final visual acuity achieved in patients with mono and mixed infections
Infection Type Final Visual Acuity Total

>20/30 20/30-20/60 20/60-20/200 <20/200

Mixed infection 0 4 0 2 6
Mono infection 16 11 7 13 47
Total 16 15 7 15 53
Value Degree of freedom Significance (2‑sided)
Pearson Chi‑square 6.515a 3 0.060b
Likelihood ratio 8.258 3 0.053b
Fisher’s exact test 5.371 0.083b
a
4 cells (50.0%) have expected count <5. The minimum expected count is 0.79. bBased on 10,000 sampled tables

Hypopyon is common in eyes with fungal keratitis.[20] Chander et al.,[5] 14.1% by Garg et al.,[11] and 21% by Chaudhary
Presence of hypopyon was found associated with large infiltrate et al.[14]
size. In this study, 44.5% of patients had presenting visual
In this series, Curvularia sp. was the most frequent
acuity of less than 20/400. This frequency was significantly species identified in 66.3% of patients. In all, 61.8% of them
lower than reported by Garg et al. (71.6%).[11] Average duration were males, and ocular trauma was present in 69% of eyes.
of healing in this study was 4.8 weeks. In all, 57% patients had Thirteen (n = 13/55; 23.6%) patients of Curvularia keratitis were
final visual acuity of less than 20/200. The final visual acuity was presented with pigmented plaque‑like infiltrate. Curvularia
significantly better than the presenting visual acuity. The final sp. has been identified in almost every previously published
visual acuity was decreased in 17% eyes. In mixed infection studies,[2,5,7,13,14] except study by Saha et al.[6] from West Bengal.
group, none of the patients achieved final visual acuity better They did not identify Curvularia sp. in their series. In series
than 20/30. Use of topical steroids was found in three (n = 3/83; by Chander et al.[5] and Chaudhary et al.[14] from North India
3.6%) patients, as compared to 1.19% by Bharathi et al.,[4] 7.8% (Chandigarh, Delhi), Alternaria sp., and Bipolaris sp. were more
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1052 Indian Journal of Ophthalmology Volume 67 Issue 7

frequent than Curvularia sp. In another series by Bharathi et al.,[4] Conclusion

Cladosporium sp. and Botryodiplodia sp. were more frequent than
Curvularia sp. However, studies by Garg et al.[11] and Sengupta In conclusion, Dematiaceous fungal infections of the ocular
et al.[16] reported Curvularia sp. as the most frequently isolated surface are most commonly caused by Curvularia sp. and
fungi among dematiaceous fungal keratitis. Alternaria sp. in North India. Scedosporium sp. is associated
with the worst outcomes. Two new genera were identified in
In this series, Ulocladium was identified in five cases of this series. These are Ulocladium and Epicoccum species, and
dematiaceous fungal keratitis. Of them, four were females. both have not been reported previously as a causal organism
Three of them had history of trauma from sugarcane leaves of fungal keratitis.
during harvesting season. There was total corneal melt in
two cases. Final visual acuity was counting finger in three Financial support and sponsorship
patients, and two patients were lost to follow‑up before final Nil.
resolution. Badenoch et al. in 2006 reported a case of Ulocladium
Conflicts of interest
atrum keratitis in a 43‑year‑old man from Australia.[21] The
identification of Ulocladium in five patients was unusual. To There are no conflicts of interest.
best of our knowledge, fungal keratitis caused by Ulocladium
species is not reported from India.
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Commentary: Dematiaceous fungal highlighting the relative importance of pigmented fungi in

the etiopathogensis of fungal keratitis from North India too.[4]
keratitis: Importance of ocular Reviewing the literature on melanized fungal keratitis, some
microbiology noteworthy facts could be appreciated. While the authors
reported Curvularia sp. and Alternaria sp. as the predominant
pathogenic genera causing dematiaceous fungal keratitis,
Keratomycosis or mycotic keratitis is a significant cause of
which is comparable to earlier published reports,[1,3,5] they also
ocular morbidity affecting mostly the agrarian population in
found that, infections due to Scedosporium sp. were associated
nearly 6‑53% of cases of ulcerative keratitis, with the highest
with the worst outcomes. The authors recorded presentation
prevalence being reported in South India. [1,2] Although
of pigmented, raised, plaque‑like infiltrate in only 18% of
previously reported as rare agents of corneal ulcers, the
the patients and resolution of stromal infiltrate with corneal
melanized fungi are now emerging as an important entity
scarring was seen in 80% patients in their study. Additionally,
second only to Fusarium and Aspergillus species.[3] Dematiaceous
moulds also known as phaeohyphomycosis (phaeo is Greek two new genera, Ulocladium and Epicoccum species which
for “dark”) represent a very heterogeneous group of fungi, have not been previously reported, were identified in their
the distinguishing characteristic common to all these various series. Thus, the laboratory represents the fundamental basis
species is the presence of melanin in cell walls, which is for a definitive diagnosis and this importance may be more
responsible for the dark color of hyphae, s and conidia, and is relevant in the Indian context, where fungi and bacteria
believed to be a major virulence factor enhancing opportunism. cause corneal ulcers almost in equal proportions it is often
They have a cosmopolitan presence and the course of infection difficult to diagnose them in real life without the help of
differs with the species; hence, for clinical management it is microbiology. Though identification of melanized fungi and
paramount to obtain an accurate species identification. Clinical melanin‑like elements are possible by conventional diagnostic
impression is often suggestive but clinical features may vary procedures like KOH mount and gram‑stained smear, growth
considerably and no one clinical feature may be pathognomonic in culture is confirmatory. In culture, melanin imparts colonial
of dematiaceous fungi as it may also mimic other ocular surface pigmentation ranging from buff to pale brown in some species,
diseases, including malignant melanoma of the conjunctiva but predominantly olivaceous to brown to black. While a
and other infectious causes of keratitis. Empiric antifungal few of these black molds may display a mucoid or yeast‑like
therapy is discouraged and confirmation of the diagnosis phase, at least initially, most appear filamentous in culture.[5,6]
prior to institution of treatment is recommended and it is However, in general, dematiaceous fungi exhibit slow growth
thus imperative that clinicians remain aware of this infectious and poor morphology and therefore the clinical presentation
entity. Studying the epidemiological pattern and outcome of and diagnosis is often delayed.
dematiaceous fungal keratitis is thereby important as most of
At our institution, we have developed a special interest in
the earlier studies were published more than a decade ago.
unidentified dematiceous fungi or fungi that do not produce
Understanding geographic and temporal trends in ocular
spores or conidial structures necessary for an accurate
infections helps in focusing not only on treatment but also on
identification of species and thus get reported as unidentified.
prevention and identification of root causes.
With the introduction of newer and rapid molecular diagnostic
In this issue of the Indian Journal of Ophthalmology, the methods, nearly all species can confidently be recognized by
authors have analyzed a large cohort of 83 patients of the rDNA ITS barcoding marker. Accurate identification of
microbiologically proven dematiaceous fungal keratitis thus fungi at the species level would be of great importance as