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.

Amniotic membrane transplantation for infectious keratitis: a systematic review and meta-analysis

“… Authors Year Study design Total eyes (AMT) Total eyes (control) Causative organisms (in AMT group) Severity of ulcer $ BK FK VK AK MK NSK Kheirkhah et al 23 2012 NRCS 14 11 14 Mean = 32% (AMT) versus 33% (control) Li et al 34 2014 NRCS 53 45 53 Not reported Naeem et al 35 2004 NRCS 34 34 34 > 3 mm Altay et al 36 2016 Case series 84 – 42 42 3 mm Berguiga et al 37 2013 Case series 5 – …”

“…A number of studies have also demonstrated that AMT, when employed as multi-layer, could effectively treat IK with threatened or actual corneal perforation (up to 5 mm) 35 , 37 , 43 , 52 . Studies have demonstrated that multi-layer AMs can promote re-epithelialization of the cornea and integrate with the corneal stroma, with progressive repopulation of AM by cornea stroma-derived cells, ultimately resulting in corneal healing and thickening 70 .…”

Amniotic membrane transplantation in a 2-month-old infant with toxic epidermal necrolysis

“…This can subsequently facilitate rapid epithelial healing preventing long-term ocular morbidity during the chronic stage. 3 , 6 , 7 , 8 We present a rare case of TEN in a very young patient (2 months) that was successfully managed with AMT. The triggering factor for SJS/TEN in our case remained unclear, however it may be multifactorial.…”

Comparison of Safety and Efficacy of Intrastromal Injections of Voriconazole, Amphotericin B and Natamycin in Cases of Recalcitrant Fungal Keratitis: A Randomized Controlled Trial

“…A large number of studies have also reported on the potential use of intrastromal injections for fungal keratitis after penetrating keratoplasty and kerato-refractive procedures. [23][24][25] However, as this study was the first of its kind, we limited the study to eyes with fungal keratitis not subjected to prior corneal surgeries. Moreover, it would not have produced reliable results due to a fewer number of patients.…”