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Interface Haze After Descemet Stripping Automated Endothelial Keratoplasty

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 79-year-old woman presented to the eye emergency department with a 2-day history of right eye pain and photophobia. She had undergone an uncomplicated Descemet stripping automated endothelial keratoplasty (DSAEK) for Fuchs endothelial dystrophy in the right eye 5 months before, which improved her corrected-distance visual acuity to 20/20 OD. She denied any history of ocular trauma or cold sores, and she was taking dexamethasone, 0.1% drops 4 times a day.

At presentation, her corrected-distance visual acuity was 20/60 OD. Slitlamp examination revealed a right inflamed conjunctiva with circumcorneal hyperemia, 2 mm × 2 mm epithelial defect with a small infiltrate at the temporal cornea, 2+ cells in the anterior chamber with a 1-mm hypopyon, and a peculiar graft-host interface haze with crisscross pattern (Figure, A). Corneal scrapes were performed and samples were sent for microscopy with Gram staining, culture, and sensitivity testing. The patient was admitted on that day and commenced taking topical cefuroxime, 5%, and gentamicin, 1.5%, drops every hour around the clock, and topical steroid was discontinued. One day later, there was no improvement in the graft-host interface haze, and results of microbiological investigations, including donor rim culture, were all negative. In view of the clinical dilemma, an in vivo confocal microscopy was performed to aid the diagnosis (Figure, B).

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Post-DSAEK interface infectious keratitis secondary to fungal infection

B. Start topical and systemic antifungal treatment

The clinical challenges presented in this case included the atypical corneal haze, lack of response to the initial broad-spectrum topical dual antibiotic therapy, negative microbiological results, and risk of corneal graft rejection. The graft-host interface haze and the filamentous-like changes demonstrated on in vivo confocal microscopy were highly suggestive of filamentous fungal interface infectious keratitis (IIK). Adding oral antibiotic (choice A) would not provide any additional benefit, and restarting topical steroids would further exacerbate the fungal IIK (choice C). Removing and sending the DSAEK graft for culture and sensitivity (choice D) would be a reasonable option, but a trial of antifungal treatment (choice B) should be considered first.

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Article Information

Corresponding Author: Darren Shu Jeng Ting, FRCOphth, Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham NG7 2RD, United Kingdom (ting.darren@gmail.com).

Published Online: August 8, 2019. doi:10.1001/jamaophthalmol.2019.2745

Conflict of Interest Disclosures: Dr Ting reports support by the Fight for Sight/John Lee, Royal College of Ophthalmologists Primer Fellowship. Dr Dua reports personal fees from Dompé, Santen Pharmaceutical, VISUfarma, and Thea Pharmaceuticals outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information and Mouhamed Al-Aqaba, FRCOphth, PhD (Division of Clinical Neuroscience, School of Medicine, University of Nottingham), for performing the in vivo confocal microscopy. Dr Al-Aqaba was not compensated for this work.

References
1.
Flockerzi  E, Maier  P, Böhringer  D,  et al; all German Keratoplasty Registry Contributors.  Trends in corneal transplantation from 2001 to 2016 in Germany: a report of the DOG-Section Cornea and its Keratoplasty Registry.  Am J Ophthalmol. 2018;188:91-98. doi:10.1016/j.ajo.2018.01.018PubMedGoogle ScholarCrossref
2.
Ting  DS, Sau  CY, Srinivasan  S, Ramaesh  K, Mantry  S, Roberts  F.  Changing trends in keratoplasty in the West of Scotland: a 10-year review.  Br J Ophthalmol. 2012;96(3):405-408. doi:10.1136/bjophthalmol-2011-300244PubMedGoogle ScholarCrossref
3.
Newman  LR, Rosenwasser  GO, Dubovy  SR, Matthews  JL.  Clinicopathologic correlation of textural interface opacities in Descemet stripping automated endothelial keratoplasty: a case study.  Cornea. 2014;33(3):306-309. doi:10.1097/ICO.0000000000000057PubMedGoogle ScholarCrossref
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Fontana  L, Moramarco  A, Mandarà  E, Russello  G, Iovieno  A.  Interface infectious keratitis after anterior and posterior lamellar keratoplasty: clinical features and treatment strategies: a review.  Br J Ophthalmol. 2019;103(3):307-314. doi:10.1136/bjophthalmol-2018-312938PubMedGoogle ScholarCrossref
5.
Brasnu  E, Bourcier  T, Dupas  B,  et al.  In vivo confocal microscopy in fungal keratitis.  Br J Ophthalmol. 2007;91(5):588-591. doi:10.1136/bjo.2006.107243PubMedGoogle ScholarCrossref
6.
Chidambaram  JD, Prajna  NV, Palepu  S,  et al.  In vivo confocal microscopy cellular features of host and organism in bacterial, fungal, and acanthamoeba keratitis.  Am J Ophthalmol. 2018;190:24-33. doi:10.1016/j.ajo.2018.03.010PubMedGoogle ScholarCrossref
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