Evaluation of the Efficacy of Intrastromal Antifungal Injection in Fungal Keratitis and Prognostic Factors Affecting Treatment Response

Presenter: Hafize Gökben.

This retrospective study evaluated the clinical outcomes of intrastromal antifungal (ISAF) injections in 29 patients with fungal keratitis (mean age 54.2 years). Prior corneal surgery was the most common predisposing factor. Candida (34.5%) and Fusarium (24.1%) were the most frequently isolated pathogens. 

Following an inadequate response to empiric fortified topical antifungal therapy, patients received intrastromal voriconazole (50 µg/0.1 mL) and/or amphotericin B (5 µg/0.1 mL). ISAF treatment was initiated after a mean of 5.62 ± 5.94 days, with patients receiving an average of 3.79 ± 3.83 injections. Twenty patients (69.0%) were classified at ISAF-responsive, achieving corneal healing within a mean of 38.7 ± 19.1 days. Among refractory cases, 5 patients required corneal cross-linking and 7 underwent therapeutic keratoplasty. 

Delayed presentation (22.78 days; p=0.013) and a baseline lesion size >6 mm (p<0.001) were significantly associated with treatment failure. These findings suggest that ISAF injections may serve as a valuable adjunctive treatment in fungal keratitis unresponsive to conventional therapy, while delayed presentation and larger lesions remain important negative prognostic factors

Adjunctive Chlorhexidine in the Treatment of Filamentous Fungal Keratitis: A Multicentre Randomised Controlled Trial

Presenter: Dr Jeremy John Hoffman.

This multicentre randomised controlled trial evaluated natamycin 5% monotherapy versus natamycin 5% combined with adjunctive chlorhexidine 0.2% in 246 patients with confirmed filamentous fungal keratitis. 

At 90 days, a significant difference in best spectacle-corrected visual acuity (BSCVA) was observed between the two treatment groups, with an adjusted mean difference of −0.16 logMAR (95% CI −0.31 to −0.01; p=0.036). Corneal perforation occurred in 26.0% of eyes receiving natamycin monotherapy compared with 11.7% of eyes receiving natamycin plus chlorhexidine (. Time to epithelial healing also differed significantly between the two groups (HR≈1.40; p≈0.030). Baseline disease severity emerged as the strongest predictor of clinical outcomes. Adverse events were infrequent (2.0%) and comparable between both treatment arms. 

These findings provide definitive evidence on the efficacy of adjunctive chlorhexidine in improving outcomes in filamentous fungal keratitis.

Evisceration and Enucleation in Microbial Keratitis: Organisms, Resistance, and Patient Factors

Presenter: A/Prof. Samar Al-Swailem.

This retrospective cohort study analyzed 69 culture-positive microbial keratitis cases requiring evisceration or enucleation between 2014 and 2022. 

Patients had a mean age of 64.6 years, and 63.8% were male. Systemic comorbidities included diabetes (46.4%) and hypertension (44.9%). Most eyes (81.2%) presented with no light perception, while endophthalmitis or panophthalmitis was present in 58.0% of cases. Common ocular risk factors included pseudophakia (36.5%), glaucoma (35.7%), topical corticosteroid use (12.4%), and prior vitrectomy (7.1%). Streptococci (32.6%) and Staphylococcus spp. (25.6%) were the most frequently isolated pathogens. Penicillin resistance was observed in 32.6% of isolates, while 37.2% remained susceptible to clindamycin.

Microbial keratitis requiring globe removal was associated with advanced disease, multiple systemic and ocular comorbidities, and severe intraocular involvement, underscoring the importance of early diagnosis and timely referral to prevent vision-threatening complications.

Fungal Keratitis in Diabetic vs Non-Diabetic Patients: A Comparative Analysis of Clinical Outcomes

Presenter: Dr David Rosário Alves

This retrospective longitudinal study evaluated 66 eyes with culture-proven fungal keratitis, comparing clinical characteristics and outcomes between diabetic (DM) and non-diabetic (non-DM) patients. 

Demographic characteristics, risk factors, and microbiological profiles were largely similar between groups. DM patients exhibited significantly greater disease severity, with higher rates of hypopyon (57.1% vs. 22.2%; p=0.005) and endophthalmitis (19.0% vs. 2.2%; p=0.032). No significant differences were observed in baseline BCVA (1.5 vs 1.9 logMAR; p=0.313) and final BCVA (1.9 vs. 1.6 logMAR; p=0.793). Similarly, rates of keratoplasty, phthisis, and globe loss were comparable between groups.

Diabetes mellitus was associated with more severe inflammatory and infectious manifestations of fungal keratitis, including significantly higher rates of hypopyon and endophthalmitis. Despite the higher disease severity, visual outcomes and surgical intervention rates were comparable between diabetic and non-diabetic patients.

Evolution of Incidence, Microbiological Profile and Antibiotic Resistance in Bacterial Keratitis Before, During and After The Covid-19 Pandemic in A Tertiary Referral Centre

Presenter: Nerea Saenz Madrazo

This retrospective study evaluated changes in the microbiological profile and antimicrobial resistance patterns of bacterial keratitis before, during, and after the COVID-19 pandemic at a tertiary referral centre in Madrid. Spain. Among 124 microbiologically confirmed cases, a significant shift in pathogen distribution was observed across the three periods. 

Gram-positive bacteria, which predominated in the pre-COVID (87.8%) and COVID (81.2%) periods, declined to 54.9% post-COVID, while Gram-negative bacilli increased significantly from 12.2% to 45.1%. Pseudomonas aeruginosa emerged as the predominant pathogen in the post-COVID period, replacing the earlier dominance of Staphylococcus spp. and Streptococcus pneumoniae. In parallel, resistance to fluoroquinolones, particularly ciprofloxacin, increased significantly post-COVID compared with pre-pandemic era (19.6% vs. 7.3%). 

These findings indicate a post-pandemic shift in the epidemiology of bacterial keratitis , underscoring the important of continuous microbiological surveillance and periodic reassessment of empirical treatment strategies.

Is Corynebacterium an Emerging and Underestimated Pathogen in Infectious Keratitis? A 22-Year Epidemiological Analysis

Presenter: Dr Ariana Fuentes Zamora

This 22-year retrospective study examined trends in Corynebacterium spp. isolated from corneal scrapings at a tertiary referral hospital. Among 195 positive samples, the majority originated from the Emergency Department, and only 1.5% were classified as probable contaminants. 

A significant increase in annual Corynebacterium isolation rates was observed over the study period, with 71.3% cases occurring during 2013-2025 compared with 28.7% during 2003-2012. Additionally, 35% of positive samples showed multi-colony growth. Although seasonal variation was observed, no significant seasonal trend was identified. 

The sustained rise in Corynebacterium isolation, coupled with a low contamination rate and a substantial proportion of multi-colony growth, challenges the traditional view of Corynebacterium as incidental ocular flora. These findings suggest that Corynebacterium may represent an emerging and potentially undereecognized pathogen in infectious keratitis.

Changing Trend in The First Contact Management Profile of Infective Keratitis

Presenter: Chandradevi Shanmugam

This retrospective study from AIIMS New Delhi evaluated first-contact management of infectious keratitis and compared contemporary findings with those reported 25 years earlier. 

Among 100 consecutive patients, ophthalmologists in private practice were the initial healthcare contact in 70% of cases. Nearly half of the patients received inadequately dosed fourth-generation fluoroquinolones. Culture positivity was 73.9%, with Staphylococcus spp. (33.8%) and Pseudomonas aeruginosa (15.4%) as the most common pathogens. A large proportion of isolates demonstratedresistance to the prescribed antibiotic therapy. 

Comparison with the earlier cohort revealed persistent challenges, including delayed presentation, limited microbiological testing, and widespread empirical use of broad-spectrum antibiotics. In addition, antimicrobial resistance, particularly among Gram-positive organisms, has increased over time, highlighting the need for improved diagnostic practices, antimicrobial stewardship, and optimized management strategies for infectious keratitis.

Differences in Clinical Behaviour and Outcome of Bacterial Keratitis Based on Biofilm-Producing Ability

Presenter: Dr Sujata Das

This prospective comparative study evaluated 119 patients with culture-positive bacterial keratitis to assess the impact of bacterial biofilm production on antimicrobial resistance and clinical outcomes. Biofilm-producing (BP) organisms accounted for 72.3% of isolates, with Staphylococcus aureus being the most frequently identified pathogens. 

BP isolates demonstrated significantly higher resistance to chloramphenicol than non-biofilm-producing (BN) isolates (72.1% vs 45.5%; p=0.006). However, rates of multidrug resistance , response to medical therapy (55.8% vs 60.6%), and final visual acuity outcomes (LogMAR 1.46 vs 1.56) were comparable between the two groups. These findings suggest that while biofilm formation is associated with increased chloramphenicol resistance, it does not appear to adversely affect treatment response or visual outcomes when therapy is guided by antimicrobial susceptibility testing.

Comparison of Culture-Negative Vs Culture-Positive Fungal Keratitis: Clinical Features and Treatment Outcomes

Presenter: Dr Sujata Das

This retrospective study compared the clinical features and treatment outcomes of culture-positive (CP) and culture-negative (CN) fungal keratitis cases at a tertiary eye care centre in India. Demographic characteristics and symptom duration were similar between the two groups. The absence of prior antimicrobial therapy was more common among CP cases.

Compared with CN cases, CP cases presented with significantly poorer visual acuity and larger corneal infiltrates (both P<0.0001). CP cases also demonstrated higher treatment failure rates and required more surgical interventions, including a significantly greater proportion of major procedures such as therapeutic penetrating keratoplasty, vitreoretinal surgery, and evisceration. In contrast, CN cases showed more favorable outcomes with medical management.

These findings suggest that culture-positive fungal keratitis is associated with greater disease severity and poorer treatment outcomes than culture-negative disease. Culture positivity may therefore serve as a useful prognostic indicator and help identify patients who may require closer monitoring and more aggressive management.

Stromal Keratitis: An Ocular Presentation of Tuberculosis

Presenter: Ms Iryna Gavryliak

This case report describes a 50-year-old patient with tuberculosis-associated stromal keratitis who presented with persistent ocular redness, foreign body sensation, and progressive visual deterioration. Baseline uncorrected visual acuity in the affected eye was 0.08, with intraocular pressure of 15 mmHg. 

Slit-lamp examination revealed marked conjunctival congestion, deep corneal neovascularization, and confluent disc-shaped stromal infiltrates. Anterior segment OCT demonstrated stromal thinning with preserved epithelial thickness and and hyporeflective areas within a hyperreflective stroma, producing a characteristic “barcode” pattern consistent with corneal neovascularization. The patient was treated with systemic antitubercular therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) along with topical corticosteroids, moxifloxacin, cyclopentolate, and lubricating eye drops, Following treatment, best-corrected visual acuity improved to 0.4, conjunctival congestion resolved, and stromal infiltration decreased, although corneal neovascularization persisted. 

This case highlights the importance of considering tuberculosis in the differential diagnosis of stromal keratitis and illustrates the utility of AS-OCT in characterizing corneal involvement.

Acanthamoeba Keratitis: 14 Cases Treated with Polihexanide 0.08% in Monotherapy

Presenter: Dr Ana Hervás Ontiveros

This case series evaluated the efficacy and safety of topical polihexanide (PHMB) 0.08% monotherapy in 14 eyes with Acanthamoeba keratitis (AK) of varying severity (Stage 1, n=3; Stage 2, n=3; Stage 3, n=1; Stage 4, n=4; Stage 5, n=3). Ten patients were contact lens wearers. 

Using a standardized tapering treatment regimen, complete clinical resolution was achieved in all cases within 6 months. The median treatment duration was 122 days, and the median best-corrected visual acuity at follow-up was 20/20. Two patients required penetrating keratoplasty due to severe disease and residual central corneal scarring.  No drug-related adverse events were reported. 

These findings suggest that PHMB 0.08% monotherapy may be an effective well-tolerated treatment option for Acanthamoeba keratitis across a range of disease severities.

ESCRS 2026, 11^th – 15^th September, London, UK.