Fungal keratitis caused by Scopulariopsis brevicaulis: successful treatment with topical amphotericin B and chloramphenicol without the need for surgical debridement.

A 41-year-old man presented with a 24 hour history of a painful right eye. Nineteen months previously he had splashed molten lead into this eye. He had subsequently undergone mucous membrane grafting to repair scarred conjunctival fornices. A vascularised cornea remained with associated cicatricial entropion preventing eyelid closure. He underwent further upper fornix reconstruction using mucous membrane grafts 3 months before this admission. On admission topical treatment included hypromellose 0 3%, six times daily, chloramphenicol 0 5%, four times daily, and simple eye ointment at night. Visual acuity was perception of light. There was upper lid symblepharon with a formed fornix. The lower fornix was negligible. The cornea was keratinised with a central 2 mm diameter ulcer. Corneal scrapings were taken for microscopy and culture; microscopy revealed no organisms. Topical methicillin drops '/2 hourly and oral ciprofloxacin 500 mg twice daily were commenced. After 4 days, because of a poor clinical response, treatment was changed to topical ofloxacin and methicillin six times daily. On day 5 Scopulariopsis brevicaulis was isolated and topical amphotericin B, 4 mg/ml in distilled water, l/2 hourly, was commenced. On day 6, the topical amphotericin B concentration was reduced to 2 mg/ml because ofocular irritation (a recognised complication ofamphotericin B'). On day 7, results of fungal antibiotic disc sensitivity testing revealed that the organism was resistant to amphotericin B, 5-flucytosine, fluconazole, clotrimazole, miconazole, econazole, and nystatin, and sensitive to none. At this stage, owing to one report that the effectiveness of amphotericin B against S brevicaulis was improved in the presence of chloramphenicol,2 and as the clinical condition was unchanged after 2 days oftopical amphotericin B alone, treatment was changed to topical amphotericin B 2 mg/ml and chloramphenicol 1%, hourly by day and 2 hourly by night; other antibiotics were discontinued. The following day the ulcer size was reduced. On day 11, the patient was asymptomatic and the ulcer had resolved. On day 15, the amphotericin B and chloramphenicol drops were discontinued. Fungal culture of toe and finger nail clippings was negative.