Persistent Post-DSAEK Complication (Grand Rounds)

From EyeWiki
Original article contributed by: Ladan Espandar, M.D., M.S.
All contributors: Maria A. Woodward, MD
Assigned editor:
Review: Assigned status Up to Date by Maria A. Woodward, MD on March 11, 2015.


Persistent Post-DSAEK Complication

Financial Disclosure

  • Drs. Espandar and Heigle state that they have no financial interest, affiliation, or other relationship with the manufacturer of any commercial product discussed or with the manufacturer of any competing project.

History

History of Present Illness

Your patient is a 61-year-old white female who underwent DSAEK surgery 6 months ago. Initially she healed well, but several weeks later an infiltrate developed. It improved with topical steroids, but worsened on taper. At 6 months, she still has blurred vision and photophobia.

  • Past Medical History: Unremarkable
  • Allergies: None
  • Medications: Topical Prednisolone Acetate 1% BID
  • Family History: No glaucoma, diabetes, or macular degeneration

Examination

  • Best Corrected Vision: OD:20/20, OS:20/70
  • Pupils: 3 mm OU, good near reflex, no RAPD
  • Tonometry: OD:14, OS:16
  • Extraocular Motility: Full, Ortho
  • Visual Fields: Normal

Slit Lamp Examination

  • Lids, lashes: Normal
  • Conjunctiva: Clear OU
  • Cornea: DSAEK graft clear and center OD, a small circular (1.0 mm diameter) infiltration with mild surrounding inflammation in interface OS (Figure 1)
  • Anterior chamber: Deep & clear OU
  • Lens: PCIOL in the bag & center OU


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Fundus Examination

  • Cup/disc ratio: 0.3 OU
  • Optic nerve: Pink, sharp OU
  • Retina: Flat OU

Ancillary Testing

  • Confocal microscopy: showed a circular area of hyper reflective particles without distinguished organism or hyphae. (Figure 2)
  • Histopathology exam: showed irregular aggregation of fungal organisms, as yeast form with rare pseudohyphae formation. (Figure 3)
  • Culture: showed Candida Albicans proliferation.

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Differential Diagnosis

Interface bacterial infection

Infectious inflammation usually presents with pain and decreased vision within 10 days of surgery, with the preponderance being from gram-positive organisms.

Interface fungal infection

Fungal keratitis usually has fewer inflammatory signs and symptoms during the initial period than bacterial keratitis. Filamentous fungal keratitis frequently manifests as a gray-white, dry-appearing infiltrate that has irregular feathery or filamentous margins. Yeast keratitis is most frequently caused by Candida species, presents with superficial white, raised colonies in a structurally altered eye.

Interface epithelial ingrowth

The source of ingrowth after DSAEK might be host epithelial cells implanted during placement of donor tissue or donor epithelial cells left following eccentric trephination, as well as epithelial downgrowth through vertical venting incisions.

Interface foreign body

Debris in the interface is occasionally seen postoperatively. The principal indication for intervention is an inflammatory reaction elicited by the foreign material. Small amounts of lint, nondescript particles, or tiny metal particles from stainless steel surgical instruments are usually well tolerated.

Final Diagnosis

Interface Candida Infection

Interface Fungal Infection

  • Fungal keratitis is an uncommon complication after keratoplasty and has been reported after penetrating, anterior lamellar, and Descemet stripping keratoplasty.
  • Risk factors: Donor corneal contamination, presence of Candida in conjunctiva and adnexal microflora are risk factors for post-graft Candida infection.
  • Treatment: Early removal of the donor lenticule may reduce the risk of intraocular infection. Usually topical antifungal treatment is ineffective, and systemic antifungal agents are necessary to achieve therapeutic aqueous concentration.

Management

Treatment

Penetrating keratoplasty (PKP) This treatment is recommended because of the high likelihood of excision of source of the infection.

Follow-up

  • After PKP with 16 interrupted sutures, the course in this case was uneventful with BCVA 20/100 at last follow-up, 3 months following surgery. (Figure 4)

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References

  1. Koenig SB, Wirostko WJ, Fish RI, Covert DJ. Candida keratitis after descemet stripping and automated endothelial keratoplasty. Cornea. 2009;28(4):471-473.
  2. Yamazoe K, Den S, Yamaguchi T, Tanaka Y, Shimazaki J. Severe donor-related Candida keratitis after Descemet's stripping automated endothelial keratoplasty. Graefes Arch Clin Exp Ophthalmol. 2011;249(10):1579-825.
  3. Lee WB, Foster JB, Kozarsky AM, Zhang Q, Grossniklaus HE. Interface fungal keratitis after endothelial keratoplasty: a clinicopathological report. Ophthalmic Surg Lasers Imaging. 2011;42 Online: e44-8.
  4. Ortiz-Gomariz A, Higueras-Esteban A, Gutierrez-Ortega AR, Gonzalez-Meijome JM, Arance-Gil A, Villa-Collar C. Late-onset Candida keratitis after Descemet stripping automated endothelial keratoplasty: clinical and confocal microscopic report. Eur J Ophthalmol. 2011 Jan 12

About the Authors

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