Early deep anterior lamellar keratoplasty for fungal keratitis poorly responsive to medical treatment

Sabatino, Francesco; Sarnicola, Enrica; Sarnicola, Caterina; Tosi, Gian Marco; Perri, Paolo; Sarnicola, Vincenzo

doi:10.1038/eye.2017.228

Cited by 31 publications

(27 citation statements)

References 29 publications

(47 reference statements)

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“…As they are often young and otherwise healthy, their corneal endothelium is of far better quality than one can expect after penetrating keratoplasty (PK). Therefore, preserving the endothelium with the Descemet membrane, with total resection of the infiltrate was tried in several studies [37,38,39,40,41]. In all of them, DALK was considered as a viable alternative for PK, with considerable advantages of lower immune rejection and graft dehiscence, but limited by the depth of the fungal infiltrate -i.e.…”

Section: Case Reportmentioning

confidence: 99%

“…In all of them, DALK was considered as a viable alternative for PK, with considerable advantages of lower immune rejection and graft dehiscence, but limited by the depth of the fungal infiltrate -i.e. Sabatino et al did not consider it in ulcers deeper than 300mm [39]. The biggest disadvantage of this approach is the difficult surgical technique, and risk of leaving some fungal hyphae unnoticed in the deeper layers of the cornea, but this can be minimized with careful patient selection.…”

Section: Case Reportmentioning

confidence: 99%

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Fusarium keratitis as a growing problem – case report and literature review

Winiarczyk¹,

Borkowska²,

Mackiewicz³

2021

Ann Agric Environ Med.

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Introduction and objectives. With the rising number of contact lens users, there has been observed an increasing number of patients admitted to ophthalmology wards with severe keratitis, including those of fungal etiology. One of the most devastating specimens is Fusarium spp. If not diagnosed and treated from the onset of the symptoms, it can lead to severe visual loss, or even blindness. Case report. This a retrospective case report of a 36-year-old pregnant female diagnosed with Fusarium keratitis, not responding to topical treatment. The problem is discussed and includes the most relevant literature review. Results. Primary therapeutic keratoplasty is prone to failure due to an ongoing inflammation process in the eye, as happened in the described patient. Spread of the infection to the vitreous body necessitated the procedure of penetrating keratoplasty with lens removal, pars plana vitrectomy and silicone oil. After treatment, the inflammation resolved, and best corrected visual acuity at the 6 months follow-up was 0.5 (Snellen charts). Conclusions. There is currently no treatment for Fusarium keratitis that would offer similar results to those observed in bacterial infection treated early with antibiotics. As systemic therapy with antifungal agents is not an option in pregnant women, they are even more of a challenge. Diagnosis is quite often delayed, leading to deeper infiltration of the cornea, sometimes with vitreous involvement. For such cases, a combined approach is proposed with vitrectomy, lens removal and penetrating keratoplasty. Early surgical intervention may rescue some of the eyes non-responsive to topical and systemic treatment.

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Section: Case Reportmentioning

confidence: 99%

Section: Case Reportmentioning

confidence: 99%

Fusarium keratitis as a growing problem – case report and literature review

Winiarczyk¹,

Borkowska²,

Mackiewicz³

2021

Ann Agric Environ Med.

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“…Once fungi reach the deep stroma, they can penetrate into the anterior chamber and there is a high risk of endophthalmitis that can lead to ocular enucleation. One study suggested early deep anterior lamellar keratoplasty as a possible safe therapeutic approach to effectively eradicate fungal keratitis affecting the optic zone and poorly responsive to medical treatment, thus avoiding corneal transplant [ 12 ]. Therapeutic options against these fungi are limited by low tissue penetration in the eye due to ocular barriers.…”

Section: Introductionmentioning

confidence: 99%

Identification and molecular characterization of Subramaniula asteroides causing human fungal keratitis: a case report

et al. 2021

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Background Keratitis due to by filamentous fungi are not easy to diagnose thus causing a delay in correct therapy. There are many descriptions of keratitis due to Candida, Fusarium and Aspergillus genera. Subramaniula genus has only recently been reported to cause human infections and there are few descriptions of eye infections due to this filamentous fungus. Diagnosis of fungal keratitis is usually based on microscopic and cultural techniques of samples obtained by corneal swabbing or scraping. Considering the amount of time required to obtain culture results it is wise to use other diagnostic methods, such as molecular analyses. Therapeutic options against these fungi are limited by low tissue penetration in the eye due to ocular barriers. We describe the first case of S. asteroides human keratitis treated with isavuconazole. Case presentation We describe a rare case of fungal keratitis unresponsive to antimicrobial treatment in a 65-year-old male patient without a history of diabetes or immunological diseases. He reported that the onset of symptoms occurred during a long holiday in Cape Verde Island. Initial treatment with topical antibiotics associated to steroids were ineffective, allowing a slow clinical progression of disease to corneal perforation. On admission in our Hospital, slit-lamp examination of the left eye showed conjunctival congestion and hyperemia, a large inferior corneal ulceration with brown pigment, corneal edema, about 3 mm of hypopyon and irido-lenticular synechiae. The slow clinical progression of the disease to corneal perforation and the aspect of the ulcer were consistent with a mycotic etiology. Molecular methods used on fungal colonies isolated by Sabouraud’s dextrose agar cultures allowed the identification of Subramaniula asteroids from corneal scraping. Antimicrobial test showed a good susceptibility of this filamentous fungus to voriconazole and isavuconazole. Moreover, this fungal keratitis was successfully treated with isavuconazole, without side effects, observing a progressive clinical improvement. Conclusions Molecular methods may be useful for the identification of filamentous fungal keratitis on scraping samples thus shortening the time of diagnosis. Systemic therapy by isavuconazole could be useful to treat the filamentous fungal keratitis, reducing the possible adverse effects due to the use of voriconazole by systemic administration.

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“…[1][2][3] Although DALK has numerous benefits and its indications are increasingly expanding (keratoconus, stromal dystrophies, scars, and, recently, even active infections poorly responsive to medical treatment), the technique is commonly considered challenging. [4][5][6][7][8][9][10] Descemet's membrane (DM) rupture is the most common (4%-39% of cases) and feared intraoperative complication, accounting for the leading cause of PK conversion. 1,3,11,12 Although different strategies have been described to repair DM ruptures, this complication can be difficult to manage.…”

Section: Introductionmentioning

confidence: 99%

Total or subtotal full thickness recipient bed cut to repair donor–recipient curvature disparity in cases of DM rupture with manual DALK

Sarnicola¹,

Sarnicola²,

Cheung

et al. 2020

European Journal of Ophthalmology

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Purpose: To report how to manage a specific type of Descemet’s membrane (DM) rupture during manual DALK with a concurrent donor–recipient disparity of curvature. Methods: Case report of two patients that had DM rupture during manual DALK with a concurrent donor–recipient disparity of curvature; the recipient bed was flatter (post-infectious scar, case 1) and steeper (keratoglobus, case 2) than the donor. Preoperative diagnosis, clinical exam, and best spectacle correct visual acuity (BSCVA) have been reported. A subtotal full-thickness circular cut of the recipient bed was performed to resolve a persistent double AC in case 1 (recipient flatter than donor). A total full-thickness circular cut of the recipient bed, creating a graft made by a DALK allograft and a “DSEK autograft,” was performed to avoid a refractory double AC in case 2 (recipient steeper than donor). Evaluated outcomes included postoperative BSCVA, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double AC. Results: Surgery was successful in resolving/avoiding double AC. VA improved in both cases. No episodes of rejection were recorded. Graft remained clear at the last follow-up (6 years for case 1 and 4 years for case 2). Conclusion: The existence of a donor–recipient curvature disparity should be investigated as a possible underlying mechanism of refractory double AC. Total or subtotal full thickness recipient bed cut may be considered to repair donor–recipient curvature disparity in cases of DM rupture occurring during manual DALK. Repairing the DM rupture and avoiding a conversion to PK in high-risk transplant cases are crucial.

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Early deep anterior lamellar keratoplasty for fungal keratitis poorly responsive to medical treatment

Cited by 31 publications

References 29 publications

Fusarium keratitis as a growing problem – case report and literature review

Fusarium keratitis as a growing problem – case report and literature review

Identification and molecular characterization of Subramaniula asteroides causing human fungal keratitis: a case report

Total or subtotal full thickness recipient bed cut to repair donor–recipient curvature disparity in cases of DM rupture with manual DALK

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