Download 14394: Fungal Keratitis and Endophthalmitis After Artificial Cornea

Chief Author: Chintan Malhotra
Co-Authors: Arun K Jain, Partha Chakma
Advanced Eye centre, Post Graduate Institute of Medical Education and Research
Chandigarh, India
The authors have no financial interest to disclose.

Keratoprosthesis implantation is increasingly being performed world wide for patients with
severe corneal blindness, who are at increased risk of graft failure after a conventional full
thickness corneal transplant.1

The ‘Auro K Pro’ is a keratoprosthesis made in India , based on the Boston Type 1
keratoprosthesis design.

The most favourable indication for implantation of the Type 1 Boston K Pro remains
previous multiple failed keratoplasties. 2 With an increased safety profile , it is now also
being used as a primary procedure in high risk cases, without a history of antecedent
unsuccessful corneal grafting.3

Fungal infections after K Pro implantation are being reported with increasing frequency in
recent years.4-8 These have partly been attributed to the prolonged use of broad spectrum
antibiotics and therapeutic contact lenses after K pro implantation.4

Though the overall rate of fungal infections in eyes implanted with the Boston K Pro was
found to be 2.6% (8 of 300 eyes) in a multicentric trial,5 these were the cause of K pro
failure in 42.8% (8 of 21 eyes) cases in this series. In contrast bacterial endophthalmitis was
reported as a cause of failure in only 4.7% (1 of 21 failed cases) in the same series. 5 Thus
fungal infections are a significant emerging complication of K Pro use.
Purpose
To document the occurrence , subsequent management, course and outcome of fungal
keratitis and endophthalmitis in a patient implanted with the ‘Auro K Pro’ keratoprosthesis
having coexisting onychomycosis.
Methods
Serial Photographic demonstrating the salient clinical findings are shown in subsequent
slides for a patient who underwent implantation with an ‘Auro K Pro’
which is based on the Boston Keratoprosthesis tyoe 1 design :
Size of carrier graft taken was – 9mm
Size of PMMA backplate of the Auro K Pro- 8.5 mm with a 3 mm central hole
Clinical Profile
OD
OS
 70 year old male patient from a rural, lower
income socioeconomic background living in a
predominantly agricultural community ,
presented with bilateral corneal opacification and
vascularization secondary to trachoma .
Visual acuity OD PL+, accurate projection of
rays in all 4 quadrants, OS No perception of
light
Intraocular pressure ( Goldmann Applanation
tonometry) OD 16 mmHg OS 40 mm Hg
 B Scan of right eye: Retina on, No lens or
IOL shadow seen, Axial length 23.5 mm
Co -existing fingernail onychomycosis for which
patient had taken 6 months of systemic antifungal
therapy (Itraconazole 100 mg BD) off andon .
Aphakic Auro K Pro (+61.5 D) + bandage contact lens (BCL)
implanted OD
Surgery was uneventful except for presence of some bleed from the iris
which was adherent to the cornea. As patient was aphakic from a
cataract surgery performed 20 years ago, the blood trickled into the
vitreous cavity.
Topical vancomycin 5% was started six times/day in addition to
moxifloxacin 0.5% six times/day and prednisolone acetate 1% QID.
Epithelial defect was present initially on the carrier graft but healed by
the 10th post op day.
Visual acuity OD improved to 20/80 by the end of the third week.
Patient was called for follow up after 3 weeks.
Follow up in the sixth post operative week
A
B
C
Patient came for follow up as scheduled, was asymptomatic, had no complaints of decreased visual acuity.
BCL was missing. White thread like deposits were present on the back of the carrier graft superiorly
( Figure A) . No infiltrates were present on the anterior surface.
•Epithelial defect was present on carrier graft (Figure B)
Whitish fluffy ‘mulberry like deposits’ were also noted on the back of the stem of the keratoprosthesis (Fig C).
No vitritis was noted, media clarity remained grade 1with a good view of the fundus.
Clinical picture was suggestive of fungal keratitis. Topical steroids were stopped.
Topical + systemic antifungals were started (G. Amphoterecin B 0.15 % 1 hourly +G Natamycin 5% 1 hourly) and
Tablet Fluconazole 200 mg BD. Topical vancomycin was continued.
Patient was advised admission to monitor progress which he refused and came for follow up 3 days later.
3 days after starting anti fungals
A
B
C
 Visual acuity had decreased from 20/80 to 20/400.
An increase was noted in the infiltrates at the back of the cornea and the stem of the optic. (Fig A).
Significant vitritis was present. Media clarity had decreased to grade 3 with a faint view of the disc and
fundus (Fig. B)
In view of the clinical picture , a presumptive diagnosis of fungal keratitis progressing to fungal
endophthalmitis was made.
Intravitreal Amphotericin B (5µgms/0.1ml) + dexamethasone ( 400µgms/ 0.1 ml) + moxifloxacin
(500 µgms/0.1ml))was given and the vitreous specimen subjected to microbiological examination and
polymerase chain reaction (PCR) for pan bacterial and pan fungal genome.
Gram stain, KOH wet mount and culture from the vitreous sample were negative.
Panfungal PCR of the vitreous sample was strongly positive (Fig. C, sample No 537, lane 2)
A
B
Media clarity started improving 48 hrs after the first intravitreal injection. Fungal colonies at back of
optic stem did not show significant resolution (Fig A) .Corneal infiltrates also became more confluent and
extended from 7’o clock to 3’o clock around the front plate of the optic (Fig. B- black arrows)
Repeat intravitreal amphotericin B + dexamethasone was given 72 hours after the first injection as the eye
was unicameral and the corneal infiltrates at the back of the optic stem were not showing sufficient
resolution. Additionally Amphotericin B 5µgms/0.1ml was injected intrastromally into the carrier
graft around the edge of the infiltrates ( Fig. B- dotted line)
Over the course of the next 2 weeks fungal colonies at the back of the optic stem and the infiltrates of the
carrier graft corneal stroma started resolving ( Fig. A and B- insets). Visual acuity improved from 20/400
to 20/200.
Final Outcome / Result
A
Though the keratitis and endophthalmitis resolved ,an
epithelial defect persisted 3600 around the anterior
plate of the K pro optic stem , with significant
thinning of carrier graft in some areas.
To deal with this cryopreserved amniotic
membrane grafting ( inlay + overlay) was done
subsequently (Fig. A)
B
The patient remained stable for the next month
with a visual acuity of 20/200, healing of the
epithelial defect, vascularization of the carrier
graft, and resolution of the keratitis and
endophthalmitis. Some inflammatory vitreous
membranes persisted for which he was advised
close follow up.
The patient however missed a scheduled follow
up and 3 months later reported with decreased
visual acuity when he was detected to have
developed an inoperable closed funnel retinal
detachment (Fig. B- arrow).
Discussion

The rate of fungal colonization of the ocular surface in K Pro eyes has been reported to be
approximately 10%. Candida has been implicated as being the most common organism to
cause surface colonization (C.parapsilosis, C albicans). Surveillance cultures have however
not reported to be useful in predicting subsequent development of infection in
keratoprosthesis eyes.4

Barnes et al4 have reported that cases of fungal infection show signs of early colonization of
the contact lens or infection of the cornea days before endophthalmitis onset hence giving
time to prevent deeper infection. Consequently in western literature the visual outcome in
cases of fungal infection in KPro eyes has been reported to be good in most cases in contrast
with the very poor visual outcome of bacterial endophthalmitis cases.

Experience from the Indian subcontinent , though limited has however been different. Jain
et al6 have reported 2 cases of fungal keratitis and endophthalmitis where one eye was
eviscerated and the other lost potential for useful vision. Aspergillus fumigatus was cultured
from one case while the other showed septate hyphae on KOH wet mount.

Our case also had a poor outcome inspite of aggressive management and initial resolution. A
lack of adherence to scheduled follow ups possibly compromised the final outcome as the
inflammatory vitreous membranes progressed to a total retinal detachment.
Conclusion
Though in our case we could not identify the causative fungus (as the infiltrates were initially limited to
the back of the carrier graft and hence scrapings could not be taken ) the fluffy, mulberry like fungal
colonies seen on the back of the stem of the Auro K pro, resemble the clinical description of candida
deposits described by Barnes et al4 on the soft contact lens covering the keratoprosthesis in their case.
Multiple factors probably contributed to the development of fungal keratitis and endophthalmitis in our
case:
- environment- the patient lived in a predominantly agricultural area and belonged to the
lower socioeconomic strata probably accounting for the poor compliance and delay in seeking medical
care.
- presence of onychomycosis may have been a predisposing factor. Candida and
nondermatophytic molds are frequently the causative agents of fingernail infections in tropics and in areas
with a hot and humid climate.9,10
Outcomes after fungal keratitis/endophthalmitis in K Pro eyes in the developing countries like India, may
be much more devastating as compared to those in the western world. An interplay of environmental (e.g
hot and humid climate)and socioeconomic factors ( predominant involvement in agricultural activities ,
lack of adequate financial resources, lack of easy access to medical care, delay in seeking medical care)
may be responsible for this .
Measures like frequent changing of the contact lens, and use of topical povidone iodine wash when
the patient follows up in the hospital may help in reducing the incidence of these devastating infections.
Prophylactic long term use of topical antifungals is an area which should be explored further in the
developing nations.
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