Exophiala Keratitis: Case Series and Systematic Review

Purpose: To present the management and treatment of Exophiala fungal keratitis cases described in the literature and at the University of Wisconsin. Methods: An internal review of Exophiala cases was performed using University of Wisconsin microbiology results from years 2014 to 2024. Systematic review was performed within Pubmed and Embase databases. Inclusion criteria were cases of culture-confirmed Exophiala keratitis. Among eligible cases, clinical details were gathered through literature and chart review including age, gender, risk factors for infection, topical and/or systemic treatment, duration of treatment, surgical interventions, and clinical outcome. Results: Two cases were identified via internal retrospective review and a total of 13 reports encompassing 14 unique cases were identified via systematic review. Identified species were Exophiala dermatitidis , Exophiala jeanselmei , Exophiala phaeomuriformis , and Exophiala lacanii-corni . Risk factors for fungal keratitis were present in all cases. Pigmentation occurred in 75% of cases. All patients were treated with topical antifungals. Use of systemic agents varied. Reported antifungal minimum inhibitory concentrations were lowest for amphotericin and newer-generation azoles, higher for natamycin, and highest for fluconazole and echinocandins. Surgical intervention was required in half of all cases. Clinical cure was achieved in all cases. Conclusions: Exophiala spp. is a rare cause of infectious keratitis in eyes that are at risk for fungal infection. Early diagnosis is critical. Surgical intervention is common, but clinical cure is possible.