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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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Corresponding Author: Darren Shu Jeng Ting, FRCOphth, Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham NG7 2RD, United Kingdom (firstname.lastname@example.org).
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.
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