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 Table of Contents  
Year : 2022  |  Volume : 3  |  Issue : 2  |  Page : 37-39

Incidence of fungal keratitis in Libya: An epidemiological study

1 Department of Anesthesia and Intensive Care, Faculty of Medical Technology, University of Tripoli, Tripoli, Libya
2 Department of Medical Laboratories, Eye Hospital, Tripoli, Libya

Date of Submission07-Jan-2021
Date of Decision20-Jan-2021
Date of Acceptance23-Jan-2021
Date of Web Publication16-May-2022

Correspondence Address:
Dr. Ahmed Atia
Department of Anesthesia and Intensive Care, Faculty of Medical Technology, University of Tripoli, Tripoli
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jphpc.jphpc_2_21

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Background and Objectives: Eye infection may lead to loss of visual function or impairment, causing severe disability. The cornea is particularly sensitive, and the amount of scarring or inflammation that is relatively mild in other areas of the body may have a substantial consequence on the cornea. The aim of this study was to assess the occurrence of eye fungal infection among patients attending the Eye Hospital in Tripoli city, Libya. Methods: Seventy-one patients with ocular fungal infections were subjected to clinical and microbiological investigations. They were selected from patients attending the outpatient department, casualty, and floor of Tripoli Eye Hospital. The specimens of the external ocular infections were collected using sterile swab and inoculated to different culture media. Results: The current findings showed that the Aspergillus was the most common causative agent, being responsible for 91.54% of the all cases, it was followed by Candida albicans (8.46%). Conclusion: Knowledge of the pathological course and clinical features of fungal keratitis will undoubtedly be added in early diagnosis and treatment, with reduction in ocular morbidity.

Keywords: Clinic, dermatophytic, eye, infection

How to cite this article:
Atia A, Ashour A, Alfaigh H. Incidence of fungal keratitis in Libya: An epidemiological study. J Public Health Prim Care 2022;3:37-9

How to cite this URL:
Atia A, Ashour A, Alfaigh H. Incidence of fungal keratitis in Libya: An epidemiological study. J Public Health Prim Care [serial online] 2022 [cited 2023 Mar 26];3:37-9. Available from: http://www.jphpc.org/text.asp?2022/3/2/37/345272

  Introduction Top

Ocular fungal infections (ophthalmic mycosis) are significant causes of morbidity and blindness (or even life-threatening infections) worldwide.[1] Among corneal diseases, the major cause of blindness is microbial keratitis.[2] Ocular ulceration and trauma are major causes of corneal blindness, often subrelated, but may be responsible for 1.5–2.0 million new cases of monocular blindness per year. Furthermore, the incidence of corneal diseases varies from nation to others and also from population to population.[1] In developed countries (North America, Western Europe, and Australia), a high proportion of bacterial ulcers have been identified, and the highest proportion of corneal infections in Libya are related to fungi.[3]

A major cause of microbial keratitis is fungal keratitis.[2] An increase in its occurrence has been conveyed in recent years, but in terms of diagnosis and treatment, the disease is still a challenge.[4],[5],[6],[7] Among the prevalent causes of fungal keratitis worldwide are Aspergillus and Fusarium. Aspergillus has the worst prognosis in general, but it shows a positive response to antifungal drugs.[3],[8]

Medical suspicion is the main factor in the diagnosis of mycotic keratitis.[9] The clinical presumption of a microbial keratitis agent may be based on clinical and epidemiological evidence, and clinical suspicion may be useful in directing antimicrobial therapy and early therapy.[10] Reports on etiological and epidemiological facts of fungal keratitis patients provide valuable insights into how this possibly overwhelming corneal disease is understood, and the consequence of this condition can be enhanced by a proper understanding of the agent and host factors involved in these infectious processes.[11],[12]

If untreated, fungal keratitis may result in complications such as hypopyon formation and even sight-threatening endophthalmitis. Fungal keratitis, such as fungal scleritis, can also lead to local complications. In certain countries, it is a significant cause of mono-ocular blindness.[13],[14] There is no research on the actual prevalence and occurrence of fungal keratitis with its associated morbidity in Libya. Hence, the objectives of this study were to determine the occurrence of Eye fungal infection among patients attending the Eye Hospital in Tripoli city, Libya.

  Methods Top

The study was conducted with the approval of committee of Faculty of Medical Technology, The University of Tripoli, Libya, and was designed as a retrospective chart review. Archives of all identified cases of fungal keratitis at the Eye hospital of Tripoli from January 2009 to June 2018 were studied. Patients were diagnosed by following the International Disease Classification and by the microbiology laboratory database of the hospital. Inclusion criteria were positive culture for fungus based on their macroscopic and microscopic features.

The collected data included patient demographics, source of sample, department of the hospital, and laboratory results. All patients were involved for the analysis of occurrence, risk aspects, and laboratory outcomes. The obtained data were gathered in Microsoft excel sheath and descriptively analyzed using counts and percentages.

Ethical approval for this study (Ethical Committee MedTech_ANA21011) was provided by the Ethical Committee of Faculty of Medical Technology, the University Tripoli, on 05 January 2021.

  Results Top

Seventy-one cases of fungal keratitis were identified during the study period. Overall, 52.2% were female. However, males constituted 47.8% of patients. The most identified causative organism in the current study was Aspergillus 91.5%, followed by Candida albicans 8.5% [Table 1].
Table 1: Number of fungal isolates

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The extent of the fungal infections during the years from 2009 to 2018 and the relationships between them and the source of collection either floor, outpatient department (OPD), or casualty are shown in [Figure 1] and [Figure 2]. Most of the case samples were collected from floor constituted 84.5%., followed by OPD and causality (11.2% and 4.2%, respectively).
Figure 1: Incidence rate by departments

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Figure 2: The extent of the fungal infections during the years from 2009 to 2018 and the relationships between them and the source of collection either floor, outpatient department, or casualty

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The incidence of fungal keratitis has been gradually increasing in the years after 2009, especially after the year of 2013.

  Discussion and Conclusion Top

The patterns and consequences of fungal keratitis at the Tripoli Eye Hospital were reported in this study. Much focus has been put on the recent outbreak of fungal keratitis in soft contact lens wearers and the possible reasons for it.[15] The key conclusion of the present study is that the occurrence of fungal keratitis gradually increased in the years after 2009, especially after 2013. In contrast to the common perception of a low frequency of fungal keratitis in the North African region, a high incidence of fungal keratitis among infectious keratitis patients (32.9%) was found in our sample. The Aspergillus and Fusarium genera have caused much of the fungal infections. In Northern Africa, the higher cases of fungal keratitis can be due to a growing trend toward farming activity in this area that predisposes individuals to vegetative injury. As per the prevalent sociocultural system, males primarily go for outdoor work and the same applies to agriculture, hence the predominance of males in fungal keratitis.

One of the highest crucial causes for infectious keratitis, along with ocular and systemic diseases, is contact lens use. In previous research, contact lens-related microbial keratitis had a high incidence rate.[16] The number of wearers of contact lenses has been growing, and younger people are equipped with contact lenses and do not follow guidelines for appropriate contact lens treatment. The age mode importance of patients in this presentation study was 24 years of age.[17] In addition, orthokeratology has resulted in several people wearing contact lenses overnight.[18]

The use of drugs, particularly steroid eye drops, lowers the immune system and reduces the host defense mechanism. For various ocular disorders such as blepharitis, iridocyclitis, choroiditis, and even allergic conjunctivitis, steroids are typically administered. When unmonitored, the use of steroids for a spectrum of ocular disorders leads to fungal keratitis. Diabetes mellitus has also been identified as a predisposing factor in some patients.[3]

Often, fungal keratitis has worse clinical results than bacterial keratitis. Studies have highlighted the advantage of topical natamycin for fungal keratitis over topical voriconazole, especially among those caused by Fusarium. In addition, voriconazole did not improve overall performance, although among Fusarium ulcers, there may have been some consequence. The authors concluded that they were unable to prescribe oral voriconazole at this time, considering the rise in nonserious adverse effects.[19]

In conclusion, fungal keratitis is the leading cause of morbidity in the eye. Popular worldwide risk factors include diabetes mellitus, the use of contact lenses and corticosteroids, but the most common identifiable cause is traumatic vegetative eye injury. There is a significant variation between infectious keratitis because of its varied clinical appearance, and it has a clinical diagnostic challenge. Awareness of common-cause clinical cases, related risk factors, and presentations of complications will also aid in the early diagnosis of fungal keratitis and improved clinical outcomes.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ung L, Bispo PJ, Shanbhag SS, Gilmore MS, Chodosh J. The persistent dilemma of microbial keratitis: Global burden, diagnosis, and antimicrobial resistance. Surv Ophthalmol 2019;64:255-71.  Back to cited text no. 1
Montgomery ML, Fuller KK. Experimental models for fungal keratitis: An overview of principles and protocols. Cells 2020;9:1713.  Back to cited text no. 2
Mehta R, Mehta P, Rao R, Acharya Y, Bala S, Sowmya K. et al. A study of fungal keratitis in North Africa: Exploring risk factors and microbiological features. Int J Life Sci Sci Res 2016;2:579-82.  Back to cited text no. 3
Salera CM, Tanure MA, Lima WT, Campos CM, Trindade FC, Moreira JA. Perfil das ceratites fúngicas no Hospital São Geraldo Belo Horizonte MG. Arq Bras Oftalmol 2002;65:9-13.  Back to cited text no. 4
Jastaneiah SS, Al-Rahi AA, Abbott D. Ocular mycosis at a referral center in Saudi Arabia: A 20-year study. Saudi J Ophthalmol 2011;25:231-8.  Back to cited text no. 5
Ren Z, Liu Q, Wang Y, Dong Y, Huang Y. Diagnostic information profiling and evaluation of causative fungi of fungal keratitis using high-throughput internal transcribed spacer sequencing. Sci Rep 2020;10:1640.  Back to cited text no. 6
Hung N, Yeh LK, Ma DH, Lin HC, Tan HY, Chen HC, et al. Filamentous fungal keratitis in Taiwan: Based on molecular diagnosis. Transl Vis Sci Technol 2020;9:32.  Back to cited text no. 7
Mohammed MR, Krishnan S, Amrathlal RS, Jayapal JM, Namperumalsamy VP, Prajna L, et al. Local activation of the alternative pathway of complement system in mycotic keratitis patient tear. Front Cell Infect Microbiol 2020;10:205.  Back to cited text no. 8
Tilak R, Singh A, Maurya OP, Chandra A, Tilak V, Gulati AK. Mycotic keratitis in India: a five-year retrospective study. J Infect Dev Ctries 2010;4:171-4.  Back to cited text no. 9
Tóth G, Pluzsik MT, Sándor GL, Németh O, Lukáts O, Nagy Z et al. Clinical review of microbial corneal ulcers resulting in enucleation and evisceration in a tertiary eye care center in Hungary. J Ophthalmol 2020;2020:8283131.  Back to cited text no. 10
Gopinathan U, Garg P, Fernandes M, Sharma S, Athmanathan S, Rao GN. The epidemiological features and laboratory results of fungal keratitis: A 10-year review at a referral eye care center in South India. Cornea 2002;21:555-9.  Back to cited text no. 11
Thomas PA. Fungal infections of the cornea. Eye (Lond) 2003;17:852-62.  Back to cited text no. 12
Reddy JC, Murthy SI, Reddy AK, Garg P. Risk factors and clinical outcomes of bacterial and fungal scleritis at a tertiary eye care hospital. Middle East Afr J Ophthalmol 2015;22:203-11.  Back to cited text no. 13
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Gupta MK, Chandra A, Prakash P, Banerjee T, Maurya OP, Tilak R. Fungal keratitis in North India; spectrum and diagnosis by Calcofluor white stain. Indian J Med Microbiol 2015;33:462-3.  Back to cited text no. 14
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Manzouri B, Vafidis GC, Wyse RK. Pharmacotherapy of fungal eye infections. Expert Opin Pharmacother 2001;2:1849-57.  Back to cited text no. 15
Ozbek Z, Kang S, Sivalingam J, Rapuano CJ, Cohen EJ, Hammersmith KM. Voriconazole in the management of Alternaria keratitis. Cornea 2006;25:242–244.  Back to cited text no. 16
Lewis RE, Wiederhold NP, Klepser ME. In vitro pharmacodynamics of amphotericin B, itraconazole, and voriconazole against Aspergillus, Fusarium, and Scedosporium spp. Antimicrob Agents Chemother 2005;49:945-51.  Back to cited text no. 17
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Austin A, Lietman T, Rose-Nussbaumer J. Update on the management of infectious keratitis. Ophthalmology 2017;124:1678-89.  Back to cited text no. 19


  [Figure 1], [Figure 2]

  [Table 1]


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