Early Onset Corneal Infections After Endothelial Keratoplasty

Sahil Goel, MD (Presenting Author), Prashant Garg, MD

*The authors have no financial interests to disclosure

Introduction:Interface Infections after DSAEK are often challenging- both diagnostically and therapeutically1

Purpose: To Describe prevalance, etiology and risk factors of early onset (<6 weeks) post DSAEK infections. Also to evaluate various therapeutic options and their outcomes

Setting:L V Prasad Eye Hospital, HyderabadIndia

1) Nahum Y, Russo C, Madi S, Busin M.. Interface infection after descemet stripping automated endothelial keratoplasty: outcomes of therapeutic keratoplasty. Cornea. 2014 Sep;33(9):893-8.

- This is a retrospective interventional case series done at a tertiary care hospital in India.

- All patients undergoing Endothelial Keratoplasty (EK) from July 2008 to June 2014 were retrospectively analysed for early onset infections (<6weeks).

- Eyes with isolated post operative endophthalmitis were excluded

- Patients thus identified were studied for risk factors, etiology, management and long term outcome.

Methods:

Host CharactersticsAge {Mean (S.D.)} 47.5 (16.07) yearsSex {M:F} 8:5Interval between DSAEK and Infection {Mean (S.D.)}

11(14) days

Follow Up {Mean (S.D.)} 24 (19) months

5; 38%

4; 31%

2; 15%

1; 8%1; 8%

Indication for Endothelial Keratoplasty

Failed Graft

Pseudophakic Bullous Keratopathy

Fuch's Endothelial Dystrophy

Aphakic Bullous Keratopathy

ICE

2

2

1

11

6

Risk Factors

Increased Surgical manipulationVenting IncisionDonor Rim - Positive cultureSuture relatedAir release (S/P pupillary block)No risk factor

8, 62%3, 23%

1, 8%

1, 8%

Causative Agent

Gram Negative bacteria

Gram positive bacteria

Fungus

No organism

1) Medical management was successful only in one case of suture related surface infiltrates.

2) All other cases ended up with Therapeutic Penetrating Keratoplasty (TPK)

3) Lenticule removal was done in one patient with donor rim culture positive

4) Simultaneous Pars plana vitrectomy + intraocular antibiotics (PPV + IOAB) was done for patients with coexisting fulminant endophthalmitis

Treatment strategies:

Host Stroma only – Medical management

Interface – Therapeutic PK/ Patch graft

Lenticule only – Explant +/- Endoscraping

S. No. CausativeAgent

VisualAcuity

Presenting FeaturesManagement

Onset of Infection

1) Pseudomonas aurogenosa 20/20 Interface infiltrate (1mm) TPK 41 Days

2) P. aeruginosa 20/30 Temporal wound site (suture related) Medical mg 10 Days

3) P. aurogenosa 20/126 Stromal infiltrates (Ring) Suspected endophthalmitis TPK+PPV+IOAB 17 Days

4) Pseudomonas sp. FC 1m ? Stromal infiltrates TPK 39 Days

5) P. aeruginosa HM Stroma + lenticule Suspected endophthalmitis TPK 4 Days

6) P. aurogenosaPL+

(Phthisis) Hypopyon + Fulminant endophthalmitis

TPK + IOAB +IOL explant 2 Days

7) P. aurogenosa No PL

(Phthisis) Stromal infiltrate + Fulminant endophthalmitis TPK + PPV + IOAB 2 Days

8) Enterobacter cloace N/A Stroma + lenticuleLenticule removal

+ IOAB 1 Days

9) Staph. aureus 20/25 Interface infiltrates TPK 4 Days

10) Corynebacterium striatum 20/50 Interface infiltrates TPK 3 Days

11) Brevibacterium sp. FC 1m Interface (Pin head) TPK 5 Days

12) Aspergillus flavus PL+ Stromal (Venting related)+ Interface TPK 8 Days

13) No organism, PCR Fungus –ve 20/30 Interface + lenticule TPK 8 Days

Results:

1) With a mean follow up of 24 months (Range 3-73 months) none of the eyes had recurrence of infection at last follow up

2) Graft clarity was maintained in 6 of 13 cases at last follow up

3)Majority of early onset infections were caused by Multi-Drug Resistant (MDR) Pseudomonas

4) Of the 7 MDR cases 2 were sensitive only to colistin and 5 to imipenem and piperacillin only

5) None of the eyes transplanted with fellow donor developed infection related complication

A B

C ED

CASE 12: Fig.(A) Right eye 8 days after Phaco + PCIOL + n-DSAEK for failed therapeutic PK. (B) Magnified view shows infiltrates (*) surrounding upper right venting incision. (C) Corneal scraping showed septate hyaline fungal filaments. After 1 week of failed topical anti-fungal therapy therapeutic penetrating keratoplasty was done. (D) Hematoxylin and eosin stain of half corneal button showing epithelial downgrowth (arrow) with activated keratocytes in area of venting incision. (E) In area of surrounding infiltrates septate hyaline fungal filaments (dark arrow) are seen using Grocott's methenamine silver stain.

*

Visual outcome:

1) All 4 cases of suspected endophthalmitis had poor visual outcome, including 2 phthisical eyes.

2) Of the remaining 8 cases with long term follow up, 5 grafts survived at last follow up, with best spectacle corrected visual acuity of 20/50 or better 3) 5 of 7 patients presenting within 5 days of surgery had final visual acuity of 20/1200 or less

4) 2 patients with larger than 10 mm graft had final visual acuity of hand movements

CausativeAgent

Visual Acuity

Presenting Features

Management Risk Factors Onset of Infection

Candida glabrata1 20/25 Interface TPK Donor culture 30 daysCandida albicans2 20/40 Interface Patch Graft Donor culture 41 days

Candida parapsilosis3

20/40 Stroma + Vitreous

TPK +PCIOL removal

Venting Incision

35 days

Aspergillus fumigatus4

20/40 Lenticule +Interface

TPK - 120 days

Candida albicans2 20/50 Interface Lenticule extraction + Repeat DSAEK

Donor culture 39 days

Staph. aureus4 20/60 Stroma TPK - 35 days

Candida albicans1 No PL Interface TPK - 21 days

Candida albicans5 No PL Lenticule TPK Donor culture 7 days

1) Lee WB et al. Interface fungal keratitis after endothelial keratoplasty: a clinicopathological report. Ophthalmic Surg Lasers Imaging. 2011 Apr 14;42

2) Kitzmann AS et al. Donor-related Candida keratitis after Descemet stripping automated endothelial keratoplasty. Cornea. 2009 Aug;28(7):825-8.

3) Chew AC, Mehta JS et al. Fungal endophthalmitis after descemet stripping automated endothelial keratoplasty-a case report. Cornea. 2010 Mar;29(3):346-9.

4) Sharma N et al. Microbial keratitis after descemet stripping automated endothelial keratoplasty. Eye Contact Lens. 2011 Sep;37(5):320-2.

5) Koenig SB et al. Candida keratitis after descemet stripping and automated endothelial keratoplasty. Cornea. 2009 May;28(4):471-3.

Review of Literature

Conclusion:

1) Unlike western literature showing Fungus as predominant cause of Interface infections, our series had for having multi drug resistant Pseudomonas as the predominant cause of post endothelial keratoplasty corneal infections.

2) Early presentation after surgery, coexisting endophthalmitis, large sized graft, delayed in therapeutic penetrating keratoplasty were risk factors for poor visual outcome in cases of post DSAEK infections in our series.