Fungal Keratitis From Nail Infections: A Case Series

Fungal keratitis can be challenging to treat with poor outcomes. Immunosuppresion or a compromised ocular surface usually precede infection. We describe a case series of three patients with recurrent fungal keratitis with concurrent fungal nail infections.

Hospital Tertiary referral centre

Case 1- 39 year old with atopic eye disease and ocular hypertension on recurrent steroids presented with pain, redness and a central corneal infiltrate that grew candida. He had concurrent fingernail candida infection. Initial treatment with amphotericin drops and oral econazole for 6 months showed improvement in both nail and corneal disease. He underwent DALK surgery for central corneal scarring however the fungal keratitis recurred in the graft. Due to his high IOPs he required glaucoma surgery and maintained vision at CF.

Case 2 -  28 year old with CLL, atopic keratoconjunctivitis, keratoconus with recurrent hydrops presented with recurrent candida keratitis after developing a perforation from a persistent epithelial defect requiring amnion and a 6mm tectonic graft. Similar candida infection was found in his fingernails. He required a gunderson flap and underwent a PK with vision of HM.

Case 3 - 61 year old with background of lid surgery and lagophthalmos presented with microbial keratitis with corynebacterium on scrape results. A further scrape at 2 months was carried out due to no improvement and showed Altanaria.   In view of fungal nail disease she was treated with voriconazole. The ulcer healed, leaving a large dense corneal scar, for which penetrating keratoplasty improved the vision from CF to 6/36.

In cases of microbial keratitis, particularly if recurrent, examination of the nails for evidence of fungal infection may narrow the differential diagnosis or suggest the use of systemic therapy to treat a potential underlying source of infection. Our cases have highlighted the importance of being aware of this potential route of fungal keratitis from nails.