| Objective:Through analyzing the image characteristics of different fungal genus under the In vivo confocal microscopy in fungal keratitis,to explore the feasibility of the identification of different fungal genus,and to guide the clinical diagnosis,treatment and prognosis analysis.Methods:a retrospective study was conducted to collect 86 eyes of 85 patients with fungal keratitis diagnosed in Qilu Hospital of Shandong University from October 2014 to October 2019.When they were admitted to the hospital,they first underwent corneal scraping microscopy,fungal culture and corneal confocal microscopy,and analyzed epidemiological characteristics.To compare the sensitivity of the three clinical diagnosis methods to the first diagnosis and non first diagnosis patients and the sensitivity of confocal microscopy in patients with different results of fungal culture,to analyze the characteristics of hyphae in patients with confocal microscopy positive and the key points of distinguishing with other structure in cornea,then analyze the image characteristics of confocal microscopy in different fungal genus,including the shape,length,diameter The angle of branches,the depth of infiltration and the changes of corneal tissue,and to explore the differential diagnosis and prognosis analysis of fungal.Results:of the 85 patients,55 were male,30 were female,the ratio of male to female was 1.8:1;the average age of the patients was 50.7±19.2 years old,74.1%of them were farmers;the main cause of the disease was corneal trauma(56.4%),and 43.5%of them were plant trauma.1)Sensitivity of three diagnostic methods:the positive rate of confocal microscopy was 88.4%,corneal scraping microscopy 64.0%,fungal culture 41.9%,including Fusarium in 26 cases(72.2%),Aspergillus in 6 cases(16.7%),Alternaria in 4 cases(11.1%);the positive rate of laser confocal microscopy was 80%.In 70 eyes of 69 patients without first diagnosis,the positive rate of fungi was 87.1%by confocal microscopy,62.9%by corneal scraping microscopy and 40.0%by fungal culture.The positive rate of confocal microscopy was significantly higher than that of laboratory examination,the difference was statistically significant(P?0.001)2)The mycelia identification of different genera under confocal microscope Fusarium is mostly arborization(80.8%),branching angle is 82.7°±6.7°,length is 255.7±85.8um,diameter is 3.8 ± 0.8um,invasion depth is 160.4 ± 115.8um,and some hypha(23.1%)have high reflective round spores;Aspergillus is mostly vermiform(83.3%),branching angle is 45.1°±10.1°,The length is 101.4 ±50.5um,the diameter is 2.9 ± 0.5um,the invasion depth is 77.3 ± 33.9um,no spores are found;Alternaria is mostly dendriform(75.0%),with few branches,the branching angle is 63.3± 20.4°,the length is 216.0 ± 82.6um,the diameter is 4.6 ± 0.9um,the invasion depth is 108.2±57.8um,and most of them(75.0%)have high reflective round spores.The mycelia of Fusarium and Alternaria are mainly arborization,but Aspergillus is mainly vermicular,their morphological differences were statistically significant(P?0.05);the mycelia length of Fusarium and Alternaria is larger than Aspergillus(P?0.0001);the mycelia diameter of Alternaria is larger than Fusarium and Alternaria,and Fusarium is larger than Aspergillus(P?0.0001);The branch angle of Fusarium is higher than Alternaria and Aspergillus(P?0.0001),and the branch angle of Alternaria is higher than Aspergillus(P?0.01),the difference is statistically significant;there is no statistically significant difference in the depth of mycelial infiltration among the three species(P?0.05);most of Alternaria has spores,while Aspergillus has no significant spores,the difference was statistically significant(P?0.05).In addition,under confocal microscope,fungal hyphae need to be differentiated from corneal nerve fibers,dendritic cell,reticular structure formed after disintegration of anterior elastic layer of cornea,proliferative corneal fiber tissue structure,corneal neovascularization and drug crystallization in corneal stroma.3)Changes of corneal tissue after different fungal infection:a large number of inflammatory cell infiltration,dendritiform cells(DFCs),stellate interconnected cells and high reflective spots attached to the endothelial layer were found in the corneal stroma.The percentage of stromal DFCs is 83.3%in Aspergillus,23.1%in Fusarium and 25.0%in Alternaria,The difference is statistically significant(P?0.05);The percentage of stellate interconnected cells is 88.5%in Fusarium,50.0%in Aspergillus and 25.0%in Alternaria,the percentage of Fusarium was significantly higher than that of Alternaria(P?0.05),There is inflammatory cell infiltration in the stroma of the three fungi,and most of them had high reflective spots attached to the endothelium,no significant difference(P?0.05).4)Prognosis analysis:in 85 patients,70.5%of them are treated with drugs alone,21.8%of them are improved with focus resection,matrix injection,anterior chamber flushing etc,6.4%with penetrating keratoplasty and 1.3%with eyeball extraction;Analyzing the infiltration depth and morphological characteristics of hyphae under confocal microscope.It was found that the depth of hyphae infiltration was related to prognosis(P?0.01).The depth of hyphae infiltration in patients undergoing penetrating keratoplasty and eyeball extraction is significantly greater;the difference of hyphae morphology was not related to prognosis(P?0.05).Among the three fungi,Fusarium 69.2%showed severe,Aspergillus 50%showed severe,Alternaria 75%showed severe,there is no significant difference in their severity(P?0.05).Most of the three fungi reached the clinical recovery level after drug treatment.The cure rate of Aspergillus and Alternaria was higher than that of Fusarium.The operation rate of Fusarium infection was higher than others,but the prognosis level of the three fungi was not statistically significant(P?0.05).Most of the patients were cured by antifungal drugs.Conclusion:Fusarium is the main pathogen of fungal keratitis,followed by Aspergillus and Alternaria.Three kinds of fungi are common in farmers.Corneal trauma,especially plant trauma is the main cause.The positive rate of confocal microscopy in the diagnosis of fungal keratitis was significantly higher than that of corneal scraping microscopy and fungal culture.For patients with non first diagnosis of fungal keratitis and patients with negative fungal culture,confocal microscopy still maintained a high sensitivity,which was significantly better than that of corneal scraping microscopy and fungal culture.According to the characteristics of hyphae under confocal microscope and the changes of corneal tissue,three common pathogenic bacteria can be preliminarily identified and the therapeutic effect can be monitored dynamically.The prognosis grade of fungal keratitis is related to the depth of mycelial invasion,but not to the morphological characteristics of mycelium.There is no significant difference in the severity and prognosis of the three common pathogenic bacteria.Most of the patients with fungal keratitis are treated with antifungal drugs effectively. |
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