Post-corneal transplant Candida keratitis - Incidence and outcome

Abstract

Purpose: To report the risk factors, clinical characteristics, and outcomes of Candida keratitis following corneal transplantation in India.

Methods: On retrospective review of medical records of 789 patients, 31 eyes developed a graft infection following corneal transplantation or keratoprosthesis and we could identify the Candida infection in only five. These cases were operated at two tertiary care centers in India. These five records were reviewed for demographics, risk factors (local and systemic) for graft infection, characteristics of infective lesion, corneal scraping results, treatment plan, and the final outcome following management.

Results: The median age of the subjects with the Candida graft infection was 62.4 ± 10.33 years (range, 62-71 years). All patients were males. The predominant risk factors included repeat corneal transplantation (5/5), prolonged usage of topical steroids (5/5), and epithelial defects (4/5). The clinical characteristics included infiltrates of variable configuration like powdery deposits, white plaque, fluffy white infiltrate, and crystalline keratopathy. The smear showed budding yeasts in all five cases whereas culture was positive in four out of five cases. The final outcome with antifungals (systemic [4/5] and topical [5/5]) is variable. Two eyes underwent evisceration, two eyes had scar formation in the failed grafts, and one patient succumbed to the systemic disease 1-month post-corneal infection.

Conclusion: Candida keratitis, in India, seems to be an emerging pathology following corneal transplantation and has a varied presentation. Though the outcomes following management seem to be grim, however, such infection can easily be avoided by a timely reduction of the risk factors.

Keywords: Candida graft infection; India; corneal transplantation.

Figure 1

Depicts varied clinical features of Candida keratitis as plaque like deposit (a), powdery deposits (b, c and d), fluffy whitish infiltrate (e) and crystalline keratopathy (f)

Figure 2

Budding yeast in 10% KOH mount in patient 1 (2a), budding yeast in Gram stain X100 in patient 4 (b), budding yeast in Gram stain X100 in patient 5 (3b), yeast cells on calcofluor white stain X100 under the fluorescent microscope in patient 5 (2d), Candida growth on blood agar in patient 4 (2e), Candida growth on chocolate agar in patient 5 (2e)

Figure 3

Endophthalmitis in patient 1 (3a), panophthalmitis in patient 3 (3b), endophthalmitis with severe graft infection in patient 4 (3d), healed keratitis with scar formation in turgid graft in patient 5 (3c)