Recent Perspectives in the Management of Fungal Keratitis

Mycotic keratitis is common in warm, humid regions with a varying profile of pathogenic fungi according to geographical origin, socioeconomic status, and climatic condition. Clinical diagnosis can be challenging in difficult cases and those refractory to treatment. Fungal hyphae on microscopic exami...

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Autores principales:	Nimmy Raj, Murugesan Vanathi, Nishat Hussain Ahmed, Noopur Gupta, Neiwete Lomi, Radhika Tandon
Formato:	article
Lenguaje:	EN
Publicado:	MDPI AG 2021
Materias:	mycotic fungal keratitis refractory keratitis metagenomic deep sequencing polyenes azoles Biology (General) QH301-705.5
Acceso en línea:	https://doaj.org/article/d4bbcd08570c4da58e04067c9ff8735a
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spelling	oai:doaj.org-article:d4bbcd08570c4da58e04067c9ff8735a2021-11-25T18:05:37ZRecent Perspectives in the Management of Fungal Keratitis10.3390/jof71109072309-608Xhttps://doaj.org/article/d4bbcd08570c4da58e04067c9ff8735a2021-10-01T00:00:00Zhttps://www.mdpi.com/2309-608X/7/11/907https://doaj.org/toc/2309-608XMycotic keratitis is common in warm, humid regions with a varying profile of pathogenic fungi according to geographical origin, socioeconomic status, and climatic condition. Clinical diagnosis can be challenging in difficult cases and those refractory to treatment. Fungal hyphae on microscopic examination and culture isolation have been the gold standard in the laboratory diagnosis of fungal keratitis. A culture isolate of the aetiological fungus is essential to perform antifungal susceptibility testing. As the culture isolation of fungi is time-consuming, causing delays in the initiation of treatment, newer investigative modalities such as in vivo confocal microscopy and molecular diagnostic methods have recently gained popularity. Molecular diagnostic techniques now help to obtain a rapid diagnosis of fungal keratitis. Genomic approaches are based on detecting amplicons of ribosomal RNA genes, with internal transcribed spacers being increasingly adopted. Metagenomic deep sequencing allows for rapid and accurate diagnosis without the need to wait for the fungus to grow. This is also helpful in identifying new emerging strains of fungi causing mycotic keratitis. A custom-tear proteomic approach will probably play an important diagnostic role in future in the management of mycotic keratitis. Positive repeat cultures are being suggested as an important gauge indicative of a poor prognosis. Positive repeat fungal cultures help to modify a treatment regimen by increasing its frequency, providing the addition of another topical and oral antifungal agent along with close follow-up for perforation and identifying need for early therapeutic keratoplasty. The role of collagen crosslinking in the treatment of fungal keratitis is not convincingly established. Rapid detection by multiplex PCR and antifungal susceptibility testing of the pathogenic fungi, adopted into a routine management protocol of fungal keratitis, will help to improve treatment outcome. Early therapy is essential in minimizing damage to the corneal tissue, thereby providing a better outcome. The role of conventional therapy with polyenes, systemic and targeted therapy of antifungal agents, newer azoles and echinocandins in fungal keratitis has been widely studied in recent times. Combination therapy can be more efficacious in comparison to monotherapy. Given the diversity of fungal aetiology, the emergence of new corneal pathogenic fungi with varying drug susceptibilities, increasing the drug resistance to antifungal agents in some genera and species, it is perhaps time to adopt recent molecular methods for precise identification and incorporate antifungal susceptibility testing as a routine.Nimmy RajMurugesan VanathiNishat Hussain AhmedNoopur GuptaNeiwete LomiRadhika TandonMDPI AGarticlemycoticfungal keratitisrefractory keratitismetagenomic deep sequencingpolyenesazolesBiology (General)QH301-705.5ENJournal of Fungi, Vol 7, Iss 907, p 907 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	mycotic fungal keratitis refractory keratitis metagenomic deep sequencing polyenes azoles Biology (General) QH301-705.5
spellingShingle	mycotic fungal keratitis refractory keratitis metagenomic deep sequencing polyenes azoles Biology (General) QH301-705.5 Nimmy Raj Murugesan Vanathi Nishat Hussain Ahmed Noopur Gupta Neiwete Lomi Radhika Tandon Recent Perspectives in the Management of Fungal Keratitis
description	Mycotic keratitis is common in warm, humid regions with a varying profile of pathogenic fungi according to geographical origin, socioeconomic status, and climatic condition. Clinical diagnosis can be challenging in difficult cases and those refractory to treatment. Fungal hyphae on microscopic examination and culture isolation have been the gold standard in the laboratory diagnosis of fungal keratitis. A culture isolate of the aetiological fungus is essential to perform antifungal susceptibility testing. As the culture isolation of fungi is time-consuming, causing delays in the initiation of treatment, newer investigative modalities such as in vivo confocal microscopy and molecular diagnostic methods have recently gained popularity. Molecular diagnostic techniques now help to obtain a rapid diagnosis of fungal keratitis. Genomic approaches are based on detecting amplicons of ribosomal RNA genes, with internal transcribed spacers being increasingly adopted. Metagenomic deep sequencing allows for rapid and accurate diagnosis without the need to wait for the fungus to grow. This is also helpful in identifying new emerging strains of fungi causing mycotic keratitis. A custom-tear proteomic approach will probably play an important diagnostic role in future in the management of mycotic keratitis. Positive repeat cultures are being suggested as an important gauge indicative of a poor prognosis. Positive repeat fungal cultures help to modify a treatment regimen by increasing its frequency, providing the addition of another topical and oral antifungal agent along with close follow-up for perforation and identifying need for early therapeutic keratoplasty. The role of collagen crosslinking in the treatment of fungal keratitis is not convincingly established. Rapid detection by multiplex PCR and antifungal susceptibility testing of the pathogenic fungi, adopted into a routine management protocol of fungal keratitis, will help to improve treatment outcome. Early therapy is essential in minimizing damage to the corneal tissue, thereby providing a better outcome. The role of conventional therapy with polyenes, systemic and targeted therapy of antifungal agents, newer azoles and echinocandins in fungal keratitis has been widely studied in recent times. Combination therapy can be more efficacious in comparison to monotherapy. Given the diversity of fungal aetiology, the emergence of new corneal pathogenic fungi with varying drug susceptibilities, increasing the drug resistance to antifungal agents in some genera and species, it is perhaps time to adopt recent molecular methods for precise identification and incorporate antifungal susceptibility testing as a routine.
format	article
author	Nimmy Raj Murugesan Vanathi Nishat Hussain Ahmed Noopur Gupta Neiwete Lomi Radhika Tandon
author_facet	Nimmy Raj Murugesan Vanathi Nishat Hussain Ahmed Noopur Gupta Neiwete Lomi Radhika Tandon
author_sort	Nimmy Raj
title	Recent Perspectives in the Management of Fungal Keratitis
title_short	Recent Perspectives in the Management of Fungal Keratitis
title_full	Recent Perspectives in the Management of Fungal Keratitis
title_fullStr	Recent Perspectives in the Management of Fungal Keratitis
title_full_unstemmed	Recent Perspectives in the Management of Fungal Keratitis
title_sort	recent perspectives in the management of fungal keratitis
publisher	MDPI AG
publishDate	2021
url	https://doaj.org/article/d4bbcd08570c4da58e04067c9ff8735a
work_keys_str_mv	AT nimmyraj recentperspectivesinthemanagementoffungalkeratitis AT murugesanvanathi recentperspectivesinthemanagementoffungalkeratitis AT nishathussainahmed recentperspectivesinthemanagementoffungalkeratitis AT noopurgupta recentperspectivesinthemanagementoffungalkeratitis AT neiwetelomi recentperspectivesinthemanagementoffungalkeratitis AT radhikatandon recentperspectivesinthemanagementoffungalkeratitis
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Recent Perspectives in the Management of Fungal Keratitis

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