Keratoconus Associated With Posterior Polymorphous Dystrophy

with ketoconazole, 200 mg orally twice a day. One colony of fungus had grown from cultures after three days. In vitro sensitivity testing (National Medical Mycological Reference Laboratory, Royal North Shore Hospital, Sydney) showed the isolated fungus to be resistant to amphotericin B, flucytosine, and itraconazole but sensitive to ketoconazole. The fungus was identified as P. mutabilis van Beyma by the International Mycological Institute, London. The corneal graft has remained clear with no fungal recurrence for a follow-up period of 12 months. Histopathologic examination of the corneal button showed a deep fungal abscess with hyphae penetrating Descemet's membrane to spread on the posterior surface of the cornea (Fig. 2). Previous reports of Phialophora keratomycosis are rare.!" Like most cases of keratomycosis, the infection in our patient occurred after outdoor corneal trauma.' Since the infiltrate was in the depths of the corneal scar, we believe that the organism was inoculated into the cornea at the time of the injury in March 1990. The six-month interval between the trauma and the clinical infection probably reflects the low virulence and the opportunistic nature of the organism. This case demonstrates some of the problems in the treatment of keratomycosis. After making a presumptive diagnosis, the choice of antifungal agents is difficult because identification and sensitivity testing often involve significant delay. In our case, topical natamycin therapy was selected initially because of its wide spectrum of activity." The lack of improvement then prompted addition of nystatin topically. Despite treatment, clinical progression of the infection necessitated keratoplasty.