Excisional penetrating keratoplasty for fungal interface keratitis after endothelial keratoplasty: surgical timing and visual outcome.

PURPOSE: In this paper, we describe two cases of fungal interface infectious keratitis (IIK) developed after endothelial keratoplasty (EK) who underwent delayed therapeutic penetrating keratoplasty (TPK) with a poor visual outcome. Furthermore, we conducted a review of the literature and analyzed the visual outcomes of TPK in relation to the time from IIK diagnosis. METHODS: We searched the literature for fungal IIK cases occurred after EK and treated by TPK. We identified 17 cases of fungal IIK, mostly caused by Candida spp. (88%). RESULTS: Infection was diagnosed at a median time of 21 (range 1-90 days) days after EK. The median lag time between infection diagnosis and TPK was 30 (range 7-393) days. The median distance corrected visual acuity (DCVA) measured 4-12 months after surgery was 20/40 (range 20/200-20/20). When TPK was performed within one month from diagnosis, the final median DCVA was 20/30 (range 20/100-20/20), with 83% of patients achieving ≥ 20/40 vision. When TPK was carried out later, the final median DCVA was 20/50 (range 20/200-20/22) with 44% of patients achieving ≥ 20/40 vision. One patient in the early surgery and four patients in the late surgery group showed postoperative DCVA ≤ 20/100 despite clear grafts. CONCLUSION: TPK with removal of the sequestered infection is advocated as a safe and effective measure to treat a post-EK infection. Early surgery allows a reduced exposure time to infection and therefore may result in better visual outcomes and lower risk of complications caused by prolonged inflammation.

Methicillin-Resistant Staphylococcus aureus Ocular Infection after Corneal Cross-Linking for Keratoconus: Potential Association with Atopic Dermatitis.

Purpose. To report the risk of methicillin-resistant Staphylococcus aureus (MRSA) ocular infection after UVA-riboflavin corneal collagen cross-linking in a patient with atopic dermatitis. Methods. A 22-year-old man, with bilateral evolutive keratoconus and atopic dermatitis, underwent UVA-riboflavin corneal cross-linking and presented with rapidly progressive corneal abscesses and cyclitis in the treated eye five days after surgery. The patient was admitted to the hospital and treated with broad-spectrum antimicrobic therapy. Results. The patient had positive cultures for MRSA, exhibiting a strong resistance to antibiotics. Antibiotic therapy was modified and targeted accordingly. The intravitreal reaction is extinguished, but severe damage of ocular structures was unavoidable. Conclusion. Riboflavin/UVA corneal cross-linking is considered a safe procedure and is extremely effective in halting keratoconus' progression. However, this procedure is not devoid of infectious complications, due to known risk factors and/or poor patients' hygiene compliance in the postoperative period. Atopic dermatitis is a common disease among patients with keratoconus and Staphylococcus aureus colonization is commonly found in patients with atopic dermatitis. Therefore, comorbidity with atopic dermatitis should be thoroughly assessed through clinical history before surgery. A clinical evaluation within three days after surgery and the imposition of strict personal hygiene rules are strongly recommended.