Diagnosis of Fungal Keratitis in Low-Income Countries: Evaluation of Smear Microscopy, Culture, and In Vivo Confocal Microscopy in Nepal

Jeremy J Hoffman; Reena Yadav; Sandip Das Sanyam; Pankaj Chaudhary; Abhishek Roshan; Sanjay Kumar Singh; Simon Arunga; Victor H Hu; David Macleod; Astrid Leck; Matthew J Burton

doi:10.3390/jof8090955

Diagnosis of Fungal Keratitis in Low-Income Countries: Evaluation of Smear Microscopy, Culture, and In Vivo Confocal Microscopy in Nepal

J Fungi (Basel). 2022 Sep 13;8(9):955. doi: 10.3390/jof8090955.

Authors

Jeremy J Hoffman¹, Reena Yadav², Sandip Das Sanyam², Pankaj Chaudhary², Abhishek Roshan², Sanjay Kumar Singh², Simon Arunga^{1

3}, Victor H Hu¹, David Macleod^{1

4}, Astrid Leck¹, Matthew J Burton^{1

5}

Affiliations

¹ International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
² Sagarmatha Choudhary Eye Hospital, Lahan 56500, Nepal.
³ Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara P.O. Box 1410, Uganda.
⁴ MRC International Statistics & Epidemiology Group, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.
⁵ National Institute for Health Research Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London EC1V 9EL, UK.

Abstract

Clinically diagnosing fungal keratitis (FK) is challenging; diagnosis can be assisted by investigations including in vivo confocal microscopy (IVCM), smear microscopy, and culture. The aim of this study was to estimate the sensitivity in detecting fungal keratitis (FK) using IVCM, smear microscopy, and culture in a setting with a high prevalence of FK. In this cross-sectional study nested within a prospective cohort study, consecutive microbial keratitis (MK) patients attending a tertiary-referral eye hospital in south-eastern Nepal between June 2019 and November 2020 were recruited. IVCM and corneal scrapes for smear microscopy and culture were performed using a standardised protocol. Smear microscopy was performed using potassium hydroxide (KOH), Gram stain, and calcofluor white. The primary outcomes were sensitivities with 95% confidence intervals [95% CI] for IVCM, smear microscopy and culture, and for each different microscopy stain independently, to detect FK compared to a composite referent. We enrolled 642 patients with MK; 468/642 (72.9%) were filamentous FK, 32/642 (5.0%) were bacterial keratitis and 64/642 (10.0%) were mixed bacterial-filamentous FK, with one yeast infection (0.16%). No organism was identified in 77/642 (12.0%). Smear microscopy had the highest sensitivity (90.7% [87.9-93.1%]), followed by IVCM (89.8% [86.9-92.3%]) and culture (75.7% [71.8-79.3%]). Of the three smear microscopy stains, KOH had the highest sensitivity (85.3% [81.9-88.4%]), followed by Gram stain (83.2% [79.7-86.4%]) and calcofluor white (79.1% [75.4-82.5%]). Smear microscopy and IVCM were the most sensitive tools for identifying FK in our cohort. In low-resource settings we recommend clinicians perform corneal scrapes for microscopy using KOH and Gram staining. Culture remains an important tool to diagnose bacterial infection, identify causative fungi and enable antimicrobial susceptibility testing.

Keywords: Nepal; cornea; culture; diagnosis; fungal keratitis; in vivo confocal microscopy; microbial keratitis; microbiology; microscopy.

Abstract

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