Late-onset fungal interface keratitis following endothelial
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Lamellar keratoplasty has become a standard technique to replace diseased host corneal tissue, although penetrating keratoplasty may still be preferred by some. Descemet's stripping automated endothelial keratoplasty (DSAEK or DSEK) remains the primary endothelial keratoplasty (EK) procedure in the United States; Descemet's membrane endothelial keratoplasty (DMEK) may offer additional advantages in visual recovery and lower rejection rate. EK procedures involve creating an interface between the host and donor cornea; that interface may develop complications that include infectious keratitis.

A 73-year-old female underwent uncomplicated DSEK for Fuchs’ dystrophy. The donor rim was sent for culture and grew Candida. The patient showed no signs of infection but was treated empirically with oral fluconazole 200 mg twice daily for 3 months. Her graft remained clear, and her vision corrected to 20/40 but was limited by her macular degeneration. Her prednisolone acetate drops were gradually tapered down to once daily over the course of several months.
At her 1-year visit, she was still using prednisolone acetate once daily. Her visual acuity was still 20/40, and she was asymptomatic. Her eye was white and quiet, but she was found to have a white opacity in the interface of the graft and host, inferior temporal to the visual axis. The epithelium was
intact, and there were no cells in the anterior chamber.

Because of the potential fungal exposure resulting from the positive donor rim culture, the patient was started on oral fluconazole 200 mg twice daily and gatifloxacin drops four times daily. The next day, she was brought to the operating room. A venting incision was placed over the infiltrate. A needle was inserted into the incision to obtain material for culture. Amphotericin was then injected into the corneal stroma. The prednisolone acetate was discontinued. Amphotericin drops were started four times daily and gatifloxacin drops were continued four times daily. Over the next few days, the eye became more inflamed and the patient developed pain. A significant anterior chamber reaction began to develop, and the prednisolone acetate was restarted twice daily. The eye eventually quieted with the addition of the steroid drops.

A pocket of debris was visualized in the corneal optical coherence tomography image, which was diagnosed as active fungal keratitis. Due to the risk of seeding the fungal elements into the eye with a repeat DSEK, a full-thickness penetrating keratoplasty was performed. The patient has treated again with fluconazole 200 mg twice daily, amphotericin drops four times daily, gatifloxacin drops four times daily, and prednisolone acetate drops four times daily. The cornea was sent for culture and grew Candida famata, which was also detected on pathology. The patient's new corneal graft remains clear. After 20 months, her best-corrected visual acuity was 20/40 with spectacles and 20/25 with a gas permeable contact lens.