Candida Endophthalmitis After Descemet Stripping Automated Endothelial Keratoplasty With Grafts From Both Eyes of a Donor With Possible Systemic Candidiasis

Abstract

Purpose: To report 2 cases with late postoperative Candida albicans interface keratitis and endophthalmitis after Descemet stripping automated endothelial keratoplasty (DSAEK) with corneal grafts originating from a single donor with a history of presumed pulmonary candidiasis.

Methods: Two patients underwent uncomplicated DSAEK by 2 corneal surgeons at different surgery centers but with tissue from the same donor and were referred to the Bascom Palmer Eye Institute with multifocal infiltrates at the graft-host cornea interface 6 to 8 weeks later, and anterior chamber cultures that were positive for the same genetic strain of C. albicans. Immediate explantation of DSAEK lenticules and daily intracameral and instrastromal voriconazole and amphotericin injections failed to control the infection. Thus, both patients underwent therapeutic penetrating keratoplasty with intraocular lens explantation, pars plana vitrectomy, and serial postoperative intraocular antifungal injection.

Results: Both patients are doing well at 2 years postoperatively with best-corrected vision of 20/20 and 20/30+ with rigid gas permeable lenses. One patient required repeat optical penetrating keratoplasty and glaucoma tube implantation 1 year after the original surgery. Literature review reveals that donor lenticule explantation and intraocular antifungals are often inadequate to control fungal interface keratitis, and a therapeutic graft is commonly needed.

Conclusions: Interface fungal keratitis and endophthalmitis due to infected donor corneal tissue is difficult to treat, and both recipients of grafts originating from the same donor are at risk of developing this challenging condition.

Figure 1

Slit lamp photographs of Patient 1 with post-DSAEK Candida albicans endophthalmitis. (A) 81 year-old man with multifocal infiltrates at the graft-host cornea interface and hypopyon 6 weeks after uncomplicated DSAEK. The donor rim culture was positive for C. albicans at 7 days. (B) Three days after donor lenticule removal, intensive topical amphotericin B (5 mg/mL) and voriconazole (10 mg/mL), and daily intracameral and intrastromal injections of amphotericin B (5 μg) and voriconazole (100 μg), the infiltrates within the host cornea are significantly larger in size. The patient underwent therapeutic penetrating keratoplasty, intraocular lens and capsule removal, and pars plana vitrectomy. (C) The large therapeutic graft failed and optical penetrating keratoplasty and glaucoma tube shunt implantation were performed 6 months later. At 2 years of follow up the patient refracts to 20/30+ with a rigid gas permeable lens.

Figure 1

Slit lamp photographs of Patient 1 with post-DSAEK Candida albicans endophthalmitis. (A) 81 year-old man with multifocal infiltrates at the graft-host cornea interface and hypopyon 6 weeks after uncomplicated DSAEK. The donor rim culture was positive for C. albicans at 7 days. (B) Three days after donor lenticule removal, intensive topical amphotericin B (5 mg/mL) and voriconazole (10 mg/mL), and daily intracameral and intrastromal injections of amphotericin B (5 μg) and voriconazole (100 μg), the infiltrates within the host cornea are significantly larger in size. The patient underwent therapeutic penetrating keratoplasty, intraocular lens and capsule removal, and pars plana vitrectomy. (C) The large therapeutic graft failed and optical penetrating keratoplasty and glaucoma tube shunt implantation were performed 6 months later. At 2 years of follow up the patient refracts to 20/30+ with a rigid gas permeable lens.

Figure 1

Slit lamp photographs of Patient 1 with post-DSAEK Candida albicans endophthalmitis. (A) 81 year-old man with multifocal infiltrates at the graft-host cornea interface and hypopyon 6 weeks after uncomplicated DSAEK. The donor rim culture was positive for C. albicans at 7 days. (B) Three days after donor lenticule removal, intensive topical amphotericin B (5 mg/mL) and voriconazole (10 mg/mL), and daily intracameral and intrastromal injections of amphotericin B (5 μg) and voriconazole (100 μg), the infiltrates within the host cornea are significantly larger in size. The patient underwent therapeutic penetrating keratoplasty, intraocular lens and capsule removal, and pars plana vitrectomy. (C) The large therapeutic graft failed and optical penetrating keratoplasty and glaucoma tube shunt implantation were performed 6 months later. At 2 years of follow up the patient refracts to 20/30+ with a rigid gas permeable lens.

Figure 2

Slit lamp photographs of Patient 2 with post-DSAEK Candida albicans endophthalmitis with graft originating from the same donor as Patient 1. (A) 67 year-old man with fluffy-appearing infiltrates at the graft-host cornea interface and hypopyon 8 weeks after routine DSAEK for corneal edema due to Fuchs’ endothelial dystrophy. The donor rim culture was negative at 4 days and the anterior chamber culture grew the same genetic strain of C. albicans as Patient 1. Immediate donor lenticule removal and daily intracameral and intrastromal injections of amphotericin B (5 μg) and voriconazole (100 μg) failed to control the infection. A therapeutic graft, cryotherapy to the peripheral infiltrates, explantation of the intraocular lens and pars plana vitrectomy were done. (B) The graft remains clear at 2 years of follow up and the patient refracts to 20/20 with a rigid gas permeable lens.

Figure 2

Slit lamp photographs of Patient 2 with post-DSAEK Candida albicans endophthalmitis with graft originating from the same donor as Patient 1. (A) 67 year-old man with fluffy-appearing infiltrates at the graft-host cornea interface and hypopyon 8 weeks after routine DSAEK for corneal edema due to Fuchs’ endothelial dystrophy. The donor rim culture was negative at 4 days and the anterior chamber culture grew the same genetic strain of C. albicans as Patient 1. Immediate donor lenticule removal and daily intracameral and intrastromal injections of amphotericin B (5 μg) and voriconazole (100 μg) failed to control the infection. A therapeutic graft, cryotherapy to the peripheral infiltrates, explantation of the intraocular lens and pars plana vitrectomy were done. (B) The graft remains clear at 2 years of follow up and the patient refracts to 20/20 with a rigid gas permeable lens.