Fungal keratitis and endophthalmitis after implantation of type 1 keratoprosthesis

Abstract

A 70-year-old patient who underwent uneventful primary implantation of Auro K Pro (a Type I Boston Keratoprosthesis-based device), developed infiltrates in the deep stroma of the carrier corneal graft and exudates on the optic stem of the keratoprosthesis assembly, 6 weeks postoperatively, which subsequently progressed to endophthalmitis. Vitreous tap was positive for a panfungal polymerase chain reaction, although corneal scrapings for both Gram stain and KOH wet mount yielded negative results. Aggressive management with systemic, topical, intravitreal, and intrastromal antifungal agents resulted in an initial resolution, but residual inflammatory vitreous membranes persisted. The patient was then lost to follow-up and presented 3 months later with a total, inoperable retinal detachment. Fungal infections after keratoprosthesis implantation remain a significant concern and may be associated with poor outcomes in the developing countries due to interplay of environmental and socioeconomic factors. Management protocols may need to be modified in accordance with the prevailing conditions in these regions.

Keywords: Endophthalmitis; fungal infections; keratitis; keratoprosthesis.

Figure 1

(a) Auro K pro (b) clearly visible posterior pole (c) infiltrates at back of carrier graft 6-weeks postoperatively (d) fluffy deposits on keratoprosthesis stem (e) increasing infiltrates after 3 days of antifungal therapy (f) development of vitritis (g) vitreous tap polymerase chain reaction positive for panfungal genome (h) dotted line represents site of intrastromal injection of amphotericin B for confluent infiltrates (i and j) decreasing infiltrates after intravitreal and intrastromal amphotericin B (k) amniotic membrane graft for nonhealing epithelial defect (l) closed funnel retinal detachment at the last follow-up