Ocular Microbiology and Immunology Group
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POSTER PRESENTATION

Predictors of Visual Acuity Improvement in Fungal Keratitis:
A Multivariate Analysis

Mamta Agarwal, Ashley Zhou, Elizabeth Nguyen, Golshan Latifi

Joe R. & Teresa Lozano Long School of Medicine, Department of Ophthalmology, UT Health San Antonio, San Antonio, Texas

Purpose: To identify sociodemographic and clinical factors associated with visual outcomes in patients with fungal keratitis.

Methods: Electronic health records of patients presenting with infectious keratitis (ICD-10 code H16) to a tertiary teaching hospital in South Texas from August 2019 to October 2024 were reviewed. Only patients with culture- or confocal microscopy-confirmed fungal keratitis were included. After excluding patients lost to follow-up (n=15), 37 eyes from 37 patients (23M, 14F) were analyzed. The primary outcome was defined as any change in best-corrected visual acuity (BCVA) from presentation to 3 months or at resolution if before 3 months. Good visual outcome was defined as any improvement in BCVA compared to presentation; poor visual outcome was defined as unchanged or worsened BCVA. Nineteen variables were analyzed independently using descriptive analysis, including eight risk factors (contact lens use, history of ocular trauma, history of ocular surface disease, prior ocular surgery, type 2 diabetes mellitus, history of topical steroid use, immunosuppression, or none), five organisms (Candida, Aspergillus, Bipolaris, Fusarium, or other), three ulcer sizes (<2mm, 2-5mm, >5mm), ulcer location (central), presence of hypopyon, and topical steroid use prior to presentation. Odds ratios with 95% confidence intervals were calculated for each variable. Statistical significance was defined as p < 0.05.

Results: Good visual outcomes (improvement in BCVA) occurred in 19 of 37 patients (51.4%). Ulcer size < 2mm was associated with universal improvement (6/6 patients; p = 0.02). Conversely, ulcer size > 5mm was significantly associated with lower odds of improvement (2/11 patients; OR: 0.125, 95% CI: 0.011-0.786, p = 0.01). Prior history of ocular surface disease and prior ocular surgery were both associated with poor visual outcomes (0/5 patients and 0/4 patients, respectively; OR: 0.000 for both, p = 0.02 and p = 0.05, respectively). Among fungal isolates, Aspergillus showed the highest proportion of improvement (4/5 patients) followed by Bipolaris (3/6 patients), though these differences were not statistically significant. Topical steroid use prior to presentation was associated with poorer outcomes (3/11 vs 16/26 patients, p = 0.08). Notably, presence of hypopyon, contact lens use, diabetes mellitus, and ocular trauma were not statistically significant risk factors for poor visual outcomes (p > 0.05).

Conclusions: Ulcer size represents the strongest predictor of visual outcomes in fungal keratitis, with an inverse relationship between ulcer diameter and good visual improvement. Small ulcers (< 2mm) demonstrate favorable prognosis, while large ulcers (> 5mm) carry poor prognosis with low improvement odds. Early detection and initiation of treatment before ulcer enlargement may improve visual outcomes. Furthermore, identification of high-risk factors such as pre-existing ocular surface disease or prior ocular surgery may guide clinical decision making and inform further treatment and management.