Exophiala Keratitis following Descemet Stripping Automated E
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A 68-year-old male, diagnosed with pseudophakic bullous keratopathy, underwent Descemet Stripping Automated Endothelial Keratoplasty in the right eye (RE). A postoperative follow-up was uneventful under a topical and systemic steroid regimen. The patient reported a history of eye infection caused by pine processionary (Thaumetopoea pityocampa), diagnosed and treated at a different hospital, 9 months before Descemet Stripping Automated Endothelial Keratoplasty. At the time of Descemet Stripping Automated Endothelial Keratoplasty, signs of eye infection were no longer reported. Two months after Descemet Stripping Automated Endothelial Keratoplasty, he was referred to the hospital due to keratitis on the right eye.

On examination, the best-corrected visual acuity (BCVA) of the right eye was 20/200 and 20/20 in the LE. The pupils were isocoric and isoreactive, without afferent pupillary defect. He had no pain with ocular movements. The biomicroscopic examination of the right eye revealed brown multilobular lesions within deep corneal stroma, with no conjunctival hyperaemia, secretions, or epithelial defect. The anterior chamber was deep and clear. Intraocular pressure and fundus examination were normal. The examination of his LE revealed no abnormality. An anterior segment optical coherence tomography was used to document the stromal infiltrate, showing the central infiltrates affecting all layers and the peripheral infiltrate concentrating in the deep stroma. Given the spread and extent of the infection, an urgent surgical approach was chosen; therefore, no topical or systemic antifungal was performed before surgery.

The patient underwent therapeutic penetrating keratoplasty using an 8.0?mm diameter graft over a 7.75?mm patient's cornea trephination and 16 interrupted nylon 10/00 sutures, with no incident. After PK, the medical treatment used included the standard approach, but with lower doses of systemic and topical corticosteroids due to suspected fungal etiology. The storage medium of the graft and the patient's corneal button was sent to microbiologic examination. The diagnosis was established by a positive direct examination and culture of the same fungus from the surgically obtained corneal button. There were no signs of recurrence of the infection during an extremely frequent initial follow-up; it was, therefore, decided not to medicate with antifungals, avoiding their associated toxicity. At 6 months of follow-up, no clinical signs of fungal infection developed and visual acuity was 20/200 without correction, but not all sutures had been removed.