Post-keratoplasty Infectious Keratitis: Epidemiology, Risk Factors, Management, and Outcomes

Abstract

Post-keratoplasty infectious keratitis (PKIK) represents a unique clinical entity that often poses significant diagnostic and therapeutic challenges. It carries a high risk of serious complications such as graft rejection and failure, and less commonly endophthalmitis. Topical corticosteroids are often required to reduce the risk of graft rejection but their use in PKIK may act as a double-edged sword, particularly in fungal infection. The increased uptake in lamellar keratoplasty in the recent years has also led to complications such as graft-host interface infectious keratitis (IIK), which is particularly difficult to manage. The reported incidence of PKIK differs considerably across different countries, with a higher incidence observed in developing countries (9.2–11.9%) than developed countries (0.02–7.9%). Common risk factors for PKIK include the use of topical corticosteroids, suture-related problems, ocular surface diseases and previous corneal infection. PKIK after penetrating keratoplasty or (deep) anterior lamellar keratoplasty is most commonly caused by ocular surface commensals, particularly Gramme-positive bacteria, whereas PKIK after endothelial keratoplasty is usually caused by Candida spp. Empirical broad-spectrum antimicrobial treatment is the mainstay of treatment for both PKIK, though surgical interventions are required in medically refractory cases (during the acute phase) and those affected by visually significant scarring (during the late phase). In this paper, we aim to provide a comprehensive overview on PKIK, encompassing the epidemiology, risk factors, causes, management and outcomes, and to propose a treatment algorithm for systematically managing this challenging condition.

Clinical Characteristics and Outcomes of Fungal Keratitis in the United Kingdom 2011–2020: A 10-Year Study

“…In addition, contact lens wear has been shown to be more commonly implicated in filamentous FK than yeast FK, which was demonstrated by our study and other studies [24,30]. On the other hand, yeast infections, particularly Candida spp., were commonly observed in eyes with ocular surface diseases, previous history of corneal transplantation and use of topical corticosteroids [24,30,35]. We similarly observed that yeast was more commonly associated with prior corneal surgery and the use of topical corticosteroids, though not statistically significant, likely due to a type II error as a result of low sample size.…”

“…We similarly observed that yeast was more commonly associated with prior corneal surgery and the use of topical corticosteroids, though not statistically significant, likely due to a type II error as a result of low sample size. With the shifting trend in penetrating keratoplasty to lamellar keratoplasty, interface infectious keratitis, including Candida-related infection following endothelial keratoplasty, has become increasingly common in the clinic and poses significant diagnostic and therapeutic challenges [35][36][37]. Therefore, knowledge of the risk factors can provide useful clues to the underlying causative organisms, potentially guiding the choice of antifungal treatment, especially in culture-negative FK cases.…”

Research Progress of Bioinspired Nanostructured Systems for the Treatment of Ocular Disorders

“…Keratitis is a leading cause of visual impairment and blindness. Due to increased contact lens use or corneal surgery, the incidence of keratitis has been increasing in recent years [ 88 , 89 ]. Although nanocarrier-based delivery systems can eliminate or control the infection, some problems including non-specific and uncontrolled release still exist.…”

Ocular Surface Infection Mediated Molecular Stress Responses: A Review

“…Slit-lamp examination shows the presence of corneal infiltrate which can be scraped and sent for microbiological analysis for the diagnosis [ 18 ]. Topical antibiotics are the mainstay of therapy especially in early cases but severe or recalcitrant infections may require systemic medications and in severe cases may also require surgical intervention with a therapeutic keratoplasty [ 19 ]. The choice of antibiotic depends on the suspected causative organisms and their sensitivity pattern.…”