early onset corneal infections after endothelial keratoplasty sahil goel, md (presenting author),...
TRANSCRIPT
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.