Case Series of Perforated Keratomycosis after Laser-Assisted In Situ Keratomileusis

Abstract

Background: Fungal keratitis is an extremely rare complication of laser vision correction resulting in poor visual outcomes. Amniotic membrane transplantation should be kept in mind in eyes with corneal perforation prior to penetrating keratoplasty.

Aim: To assess the outcomes of multilayered fresh amniotic membrane transplantation (MLF-AMT) in patients with severe keratomycosis after laser-assisted in situ keratomileusis (LASIK). Study design. Hospital-based prospective interventional case series.

Methods: Five eyes of 5 patients were included in the study. All cases underwent microbiological scrapings from residual bed and intrastromal injections of amphotericin (50 mcg/mL), with flap amputation if needed, followed by topical 5% natamycin and 0.15% amphotericin. MLF-AMT was performed after corneal perforation. Later, penetrating keratoplasty (PK) was performed when corneal opacity compromised visual acuity. The outcome measures were complete resolution of infection, corneal graft survival, and best-corrected visual acuity (BCVA).

Results: The mean age of patients was 22 ± 1.2 years with 4/5 (80%) were females. The mean interval between LASIK and symptom onset was 8.8 ± 1 day, and the mean interval between symptom onset and referral was 14 ± 1.4 days. Potassium hydroxide (KOH) smears showed filamentous fungi, and Sabouraud's medium grew Aspergillus in all cases. Melted flaps were amputated in 4 (80%) cases. MLF-AMT was performed in all cases due to corneal perforation after a mean time of 12.4 ± 1.2 days of antifungals. In all cases, complete resolution of infection was seen 26 ± 1.8 days after MLF-AMT, and optical PK was done at a mean of 2.4 months later. No postoperative complications after MLF-AMT or PK were observed, with a 0% incidence of corneal graft rejection, and a final BCVA ranged from 20/20 to 20/80 after a mean follow-up of 14 ± 1.1 months.

Conclusion: MLF-AMT is a safe and valid option to manage corneal perforation during keratmycosis treatment to avoid emergency therapeutic keratoplasty.

Figure 1

Slit-lamp photos of case #3 showing. (a) Descemetocele and perforation with iris prolapse and inferior AC loss 11 days after intrastromal amphotericin injection. (b) Corneal opacity and epithelialized corneal surface 5 weeks after multilayered fresh amniotic membrane transplantation. (c) Clear full-thickness corneal graft secured with interrupted 10/0 nylon sutures (1^st postoperative day). (d) Healthy corneal graft 9 months after PK.

Figure 2

(a) Slit-lamp photo of case #5 at 1^st visit showing ciliary injection, central dense interface infiltrates with peripheral satellites within the edge of the flap (arrow) and hypopyon. (b) Slit-lamp photo 48 hours after flap amputation and 2^nd intrastromal amphotericin injection showing diffuse dense infiltrate with evolving descemetocele (arrow). (c) Slit-lamp photo, 3 weeks after sutures removal, showing: quiet eye, epithelialized cornea, stroma filled with amniotic membrane, and formed anterior chamber (AC). (d) Ultrabiomicrosopic (UBM) image of anterior segment showing: restored corneal thickness and formed AC. (e) UBM image of anterior segment showing inferior peripheral anterior synechia (PAS). (f, g) Intraoperative pictures captured during penetrating keratoplasty (PK) showing removal of the trephined cornea and release of the PAS at 6 o'clock position (f), corneal graft secured with interrupted 10/0 nylon sutures (g). (h) Slit-lamp photos 5 months after PK showing clear and healthy corneal graft.