Successful Management of Infectious Crystalline Keratopathy with Intrastromal Antibiotic Injections

Abstract

Purpose. To report the successful treatment of a case of presumed infectious crystalline keratopathy with repeated intrastromal antibiotic injections in a cornea graft in the setting of severe ocular graft-vs.-host-disease (GVHD). Observations. A 62-year-old man with a history of ocular GVHD and tectonic penetrating keratoplasty (PK) for corneal melt from herpes zoster keratopathy developed presumed infectious crystalline keratopathy (ICK) in the corneal graft. Given the patient's complicated ocular history, chronic immunosuppression and new cardiac comorbidities, a therapeutic PK would most likely fail. Efforts were then directed to rescue the graft with minimally invasive approaches. Two separate intrastromal injections of cefuroxime and moxifloxacin successfully treated his ICK. Conclusions and Importance. This case supports a role for repeated intrastromal antibiotic injections in patients with ICK refractory to topical antibiotic therapy, which might eliminate the need for therapeutic PK and preserve vision.

Figure 1

Timeline of history of present illness. Graphical representation of the ocular and systemic disease course for this patient.

Figure 2

Slit-lamp photograph of the right eye at initial presentation. (a) A slit-beam photograph centered over the new crystalline pattern of branching thin structures in the anterior stroma. (b) A wide-beam photograph demonstrating the branch-like structures in the anterior stroma of the central visual axis (arrowhead), and nasally, a preexisting triangular anterior stromal scar (dashed outline). (c) Confocal microscopy revealed mid-stromal (195 μm deep) highly reflective needle-like structures consistent with crystalline keratopathy, but not specific for an individual pathogen.

Figure 3

Image series from surgical video demonstrating the intrastromal antibiotic injections through a 30-gauge needle. The injections were made in a circular pattern surrounding the crystalline deposits, achieving a higher concentration centrally and keeping the needle tracks away from the visual axis (image progression from (a) to (f)). Full video available here in https://www.dropbox.com/s/x0gbutn8d64a5sd/Video1.mp4?dl=0.

Figure 4

Slit-lamp photograph of the right eye 23 months after initial presentation. The “branch-like” infiltrates were still visible centrally (solid outline). Multiple linear needle tracks from the intrastromal injections were in the paracentral cornea stroma (arrowheads). The triangular 1.5 mm anterior stromal haze was stable in appearance (dashed outline).