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.

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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.

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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

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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