Recurrent Filamentous Fungal Keratitis Caused When the Primarily Selected Graft Diameter was Too Small

Abstract

Purpose To establish the importance of using a sufficiently large corneal graft in primary penetrating keratoplasty in order to prevent recurrence of fungal keratitis. Oberservations A 58-year-old female patient underwent emergency penetrating keratoplasty (diameter 7.0 mm, double running suture) for therapy-resistant fungal keratitis (Fusarium solani) at an external eye clinic. Despite intensive antifungal therapy, new fungal infiltrates appeared in the host cornea after a few days. The patient was referred to our department for further treatment. On first presentation, circular infiltrates were seen around the corneal graft with anterior chamber involvement and therapy-resistant hypopyon. We performed an emergency penetrating repeat keratoplasty (diameter of 13.0 mm, 32 interrupted sutures) combined with anterior chamber lavage and intracameral and intrastromal drug injection. Conclusion and Importance Fungal keratitis sometimes has a frustrating clinical course. Therefore, early diagnosis with effective therapy initiation is of the utmost importance. In cases of penetrating keratoplasty, optimal planning and timing (before anterior chamber involvement) should be provided. Sufficient safety distance must be ensured in the choice of graft diameter, fixation with multiple interrupted sutures, and anterior chamber lavage, as well as intracameral and intrastromal drug administration. Incomplete excision carries a risk of recurrence and endophthalmitis in the course. Close postoperative control is necessary to detect early recurrences.

Infectious Crystalline Keratopathy after Penetrating Keratoplasty with Light and Electron Microscopic Examination

“…The whitish branching opacities are usually localized in the anterior corneal stroma, but deep stromal involvement has also been described in single cases 9 . In contrast to classical infectious keratitis 10 , 11 , 12 , 13 , ICK has an indolent and less aggressive but therapy-resistant clinical course.…”

Die Fusarien-Keratitis auf dem Vormarsch – eine aktuelle klinische Übersicht

“…In contrast to Candida keratitis, which shows a more prolonged course, the acute symptomatology of Fusarium keratitis more resembles the course of bacterial keratitis with exacerbation within a few hours to days [16]. This is due to the ability to express degradative enzymes and mycotoxins, which, after passing the entry port, lead to rapid and deep corneal penetration of the Fusarium infection until it breaks through the Descemetʼs membrane [19], resulting in high rates of perforation (up to 30 % [1]) and endophthalmitis (up to 6.3 % [20,21]). Satellite lesions or pyramidal hypopyon are ▶ Table 1 Proportion of mycotic keratitis among all confirmed cases of infectious keratitis and proportion of keratitis cases caused by Fusarium species among all confirmed mycotic keratitis in selected countries at different times according to Hoffman et al [1] and Ahmadikia et al [7].…”

“…Due to the deep penetrating growth of Fusarium keratitis, infection can be limited to the deep corneal stroma. Too superficial sampling then results in a false negative culture [19,23]. Probably also due to this, the sensitivity of the culture detection for Fusarium keratitis is only 50 %; occasionally, culture detection is possible by deep stromal biopsy or anterior chamber sample [1,3].…”

Transplantatversagen nach PKP und DMEK: Was ist die beste Option?

“…Bei infektiöser Keratitis, insbesondere bei Pilzkeratitis, wird das 1. Transplantat oft zu klein gewählt 39 . Dadurch wird nicht selten eine Re-Keratoplastik mit sehr großem Durchmesser bei fortschreitendem Infektionsgeschehen nötig 40 , 41 .…”

“…In infectious keratitis, especially fungal keratitis, the 1st graft selected is often too small 39 . As a result, it is not uncommon for a very large diameter re-keratoplasty to be necessary if the infection progresses 40 , 41 .…”