Infectious Crystalline Keratopathy Following Initiation of Mycophenolate Mofetil

To present a case of infectious crystalline keratopathy (ICK) associated with recent initiation of systemic mycophenolate mofetil (MMF).

Retrospective case report.

A 68-year-old man with prior Descemet's stripping automated endothelial keratoplasty (DSAEK) in his right eye developed graft failure and was scheduled for a second DSAEK. He had been using topical prednisolone acetate four times daily in his right eye. Given a prior history of anterior uveitis, preoperative MMF was initiated 3 weeks prior to repeat DSAEK. On the day of surgery, the patient was noted to have a new large arborizing non-suppurative stromal infiltrate despite minimal visual changes or symptoms, consistent with ICK. Corneal cultures grew Streptococcus sanguinis which responded to topical antibiotics with discontinuation of MMF. Therapeutic penetrating keratoplasty (PKP) was required for corneal scarring with no further recurrence of disease. Gram stain of the host corneal tissue demonstrated persistence of intrastromal bacteria despite clinically inactive disease.

While typically reported in cases of local immunosuppression on topical steroids and/or post-PKP, infectious crystalline keratoplasty can occur shortly after the initiation of systemic immunosuppression with a rapid yet insidious onset. Bacterial colonies may persist long after clinical resolution of disease.