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Suture-Related Fungal Interstitial Interface Keratitis in Deep Anterior Lamellar Keratoplasty: A Case Report
Premalatha Santhiran1, Wan Haslina Wan Abdul Halim1, Meng Hsien Yong1
1Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS.
Abstract:
Interstitial interface keratitis (IIK) in lamellar keratoplasty is a term used to describe infectious keratitis that primarily involves the graft-host interface. It poses specific challenges due to impaired access for microbiological testing and poor penetration of antimicrobial drugs, as well as ease of deeper extension of the microorganism. A 33-year-old male with a medical history of left eye deep anterior lamellar keratoplasty (DALK) with keratoconus, subsequently complicated with steroid-induced glaucoma controlled with Xen tube insertion, presented with acute left eye pain and redness for two days due to one broken corneal graft suture at 5 o'clock position with infiltrate at the graft-host junction. He was treated for suture-related bacterial keratitis (culture-negative) with intensive single broad-spectrum topical antibiotic after suture removal. However, the condition worsened, with dense stromal infiltrate extending into the graft-host interface junction which further progressed to an endothelial plaque. Systemic and topical antifungal treatments were started with adjunctive intracameral and subconjunctival voriconazole before improvement was observed. The condition was resolved with localized scarring without the need for repeat keratoplasty. The best-corrected vision was maintained at 6/36 due to residual sutured-related astigmatism with no signs of corneal graft rejection. Lamellar keratoplasty poses an increased risk of fungal IIK even after several years if there is a predisposing factor e.g., steroid usage and broken suture. Timely diagnosis and intervention are the keys to ensure an optimal outcome.
Insights
Fungal interstitial interface keratitis (IIK) can occur years after lamellar keratoplasty, especially with risk factors like steroid use and suture issues. Early diagnosis and antifungal treatment are crucial for successful outcomes.
Area of Science:
- Ophthalmology
- Microbiology
Background:
- Interstitial interface keratitis (IIK) presents unique challenges in lamellar keratoplasty due to limited diagnostic access and poor drug penetration.
- Risk factors for IIK include steroid use and suture complications, potentially leading to deeper infections.
Observation:
- A patient with a history of deep anterior lamellar keratoplasty (DALK) for keratoconus developed acute eye pain and redness.
- Initial symptoms were attributed to suture-related bacterial keratitis but worsened despite antibiotic treatment, progressing to a dense stromal infiltrate and endothelial plaque.
Findings:
- The patient was diagnosed with fungal IIK, a rare complication following DALK.
- Treatment with systemic and topical antifungals, including intracameral and subconjunctival voriconazole, led to resolution with localized scarring.
- Best-corrected vision was maintained at 6/36, with no signs of graft rejection.
Implications:
- Lamellar keratoplasty recipients are at risk for delayed fungal IIK, even years post-surgery, particularly with predisposing factors.
- Prompt diagnosis and aggressive antifungal intervention are essential for managing fungal IIK and preserving graft function.
- This case highlights the importance of considering fungal etiology in refractory keratitis after keratoplasty.
