Fungal Infection After Descemet Membrane Endothelial Keratoplasty: Incidence and Outcomes.

PURPOSE: The aim of the study was to describe the incidence, presentation, management, and outcomes of fungal infection after Descemet membrane endothelial keratoplasty (DMEK). METHODS: Retrospective case series of culture-proven fungal infections after DMEK reported in the literature, directly by surgeons, and to the Eye Bank Association of America from January 1, 2011, to December 31, 2020. RESULTS: The domestic incidence of fungal infections, fungal keratitis, and fungal endophthalmitis after DMEK from 2011 to 2020 was 3.5, 1.3, and 2.2 per 10,000 cases, respectively, with no significant increasing trend. Thirty-four cases were identified, 14 (41.2%) published and 20 (58.8%) unpublished. Donor tissue fungal cultures were performed in 20 of the 34 (58.8%) cases and were positive in 19 of the 20 (95.0%), all but one Candida species. Recipient fungal cultures were performed in 29 of the 34 (85.3%) cases and were positive in 26 of the 29 (89.7%), all but one Candida species. Infection presented a mean of 33 ± 38 days (median 23, range 2-200, outlier 949) after transplantation: 25 (73.5%) with endophthalmitis and 9 (26.5%) with keratitis. Topical, intrastromal, intracameral, intravitreal, or systemic antifungal therapy was used in all 27 eyes with treatment data. Surgical intervention (DMEK explantation or partial removal, repeat endothelial keratoplasty, penetrating keratoplasty, and/or pars plana vitrectomy) was required in 21 of the 27 (77.8%) eyes. The corrected distance visual acuity at the last follow-up was ≥20/40 in 13 of the 27 (48.1%) eyes and counting fingers or worse in 6 of the 27 (22.2%) eyes. CONCLUSIONS: Fungal infection is a rare but serious complication of DMEK that results in counting fingers or worse corrected distance visual acuity in nearly a quarter of eyes.

Corneal Neurotization Using the Great Auricular Nerve for Bilateral Congenital Trigeminal Anesthesia.

PURPOSE: The purpose of this study was to describe an indirect corneal neurotization (CN) technique for congenital bilateral trigeminal anesthesia using the greater auricular nerve (GAN) as a donor. METHOD: CN was performed to preserve the integrity of the only seeing eye in a 4-year-old boy with pontine tegmental cap dysplasia and bilateral trigeminal anesthesia. He had recurrent corneal ulceration and scarring despite full medical treatment. The GAN was used as a donor, and the sural nerve was harvested and used as a bridge which was tunneled to the sub-Tenon space in the inferior fornix. The fascicles were distributed into the 4 quadrants and sutured to the sclera near the limbus. RESULT: This technique resulted in providing corneal sensation and improving stability of the epithelium. Corneal opacity gradually decreased allowing significant visual improvement evidenced in the early postoperative months. CONCLUSIONS: Using the GAN technique for CN bypasses trigeminal innervation and has the potential to improve corneal sensation. The GAN is a large caliber nerve and provides a large amount of axons and robust neurotization. This technique would be desirable for cases with bilateral congenital trigeminal anesthesia, such as pontine tegmental cap dysplasia.

Severe corneal melting after cataract surgery in patients prescribed topical postoperative NSAIDs and dexamethasone/neomycin combination therapy.

Three patients using a postoperative combination of topical ketorolac (Acular) and neomycin/polymyxin B sulfate/dexamethasone (Maxitrol) were diagnosed with atypical keratopathy soon after routine cataract surgery. An immediate retrospective analysis of hospital patients who had used this topical drug combination in the previous year identified 10 other patients who also had significant corneal pathology after uneventful cataract surgery. Five of the 13 affected patients had corneal melting and 1 patient had corneal perforation and endophthalmitis. At the last recorded follow-up appointment, 8 of the 13 patients had a visual acuity of 6/36 or worse. Corneal melting is a rare complication of topical nonsteroidal anti-inflammatory drugs (NSAIDs). We propose that the combined use of topical NSAIDs and other agents, such as neomycin and benzalkonium, that further compromise the corneal epithelium, should be used with vigilance and increased awareness of potential keratopathy and permanent visual morbidity.

Fungal infection after endothelial keratoplasty: association with hypothermic corneal storage.

PURPOSE: To compare the incidence of fungal infection after endothelial keratoplasty (EK) when donor tissue had been stored in hypothermic medium or organ culture. METHODS: We describe the clinical features of 10 cases of fungal infection (keratitis or endophthalmitis) following EK identified at three European centres. Case definition was the culture of fungus or a positive PCR from the host cornea or anterior chamber after EK. A survey of the incidence of infection after EK was conducted by the European Eye Bank Association. The main outcome measure was the number of cases in which donor tissue had been stored in hypothermic medium compared with organ culture. RESULTS: The 10 cases occurred between 2014 and 2017. All donor corneas had been stored in hypothermic medium sourced from three US eye banks. Three pairs of mate corneas caused infections in six recipients. Candida spp were identified from nine cases, with one isolate of Purpureocillium lilacinum. Data on 16 862 corneas supplied for EK were available from 16 European eye banks for the 5-year period from 2012. There were 17 reported cases of infection, of which 15 (88%) were fungal infections and 14 (82%) were Candida spp. Fungal infection was reported from 3 of 14 476 (0.02%) corneas supplied in organ culture compared with 12 of 2386 (0.50%) corneas supplied in hypothermic medium (p<0.0001). The incidence of infection after hypothermic storage was similar for material sourced from Europe (0.52%) or the USA (0.61%). CONCLUSIONS: Infection after EK is strongly associated with Candida spp. The possible explanations for the higher incidence of infection when tissue is stored in hypothermic medium are discussed.

Nonpenetrating femtosecond laser intrastromal astigmatic keratotomy in eyes having cataract surgery.

PURPOSE: To describe the effect of femtosecond laser intrastromal astigmatic keratotomy (AK) performed during cataract surgery. SETTING: Moorfields Eye Hospital, London, United Kingdom. DESIGN: Prospective case series. METHODS: This study comprised patients having laser cataract surgery with concurrent astigmatism management by intrastromal AK. All eyes had greater than 0.7 corneal diopter (D) cylinder. An intrastromal AK nomogram with 8.0 mm diameter paired symmetric limbal centered arcs was used. Corneal keratometry was measured preoperatively and 1 month postoperatively using a KR8100PA topographer-autorefractor. Astigmatic analyses were performed using the Alpins method considering 3 vectors-target induced astigmatism (TIA), surgically induced astigmatism (SIA) and difference vector (DV)-and calculation of coupling measures. RESULTS: In all, 196 eyes of 133 patients were analyzed. The mean TIA (equivalent to preoperative corneal cylinder) was 1.21 D ± 0.42 (SD) (range 0.75 to 2.64 D) and the mean SIA was 0.74 DC ± 0.40 (range 0.00 to 2.86). The mean difference vector was 0.74 ± 0.38 D (range 0.00 to 2.25 D). The mean correction index was 0.63 ± 0.32 (range 0.00 to 1.93), indicating that the mean astigmatism correction was 63%. Fourteen eyes (7.1%) and 7 eyes (3.6%) had an astigmatism correction of greater than 100% and greater than 120%, respectively. Overall 0%, 48.5%, and 51.5% of eyes had 0.50 D or less, 1.0 D or less, or greater than 1.0 D, respectively, preoperatively compared with 32.1%, 85.7%, and 14.3%, postoperatively. There were no cases of corneal endothelial perforation or inadvertent placement within the visual axis. CONCLUSIONS: The intrastromal AKs were easily programmed as an integral part of laser-assisted cataract surgery without additional cost, significantly reduced corneal cylinder, and appeared to be safe through 1 month of follow-up. FINANCIAL DISCLOSURE: Dr. Day was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology. Dr. Stevens has been a consultant to Optimedica Inc., now part of Abbott Medical Optics.