05 March 2023: Articles
Post-Keratoplasty Infectious Keratitis Caused by
Management of emergency care, Rare coexistence of disease or pathologyAlbaraa Alfaraidi 12ABCDEF, Mohammed Alshehri 1ABCDEF, Lamia Alhijji1ABCDEF, Ayshah Alshngeetee3ABCDEF, Rawan Alshabeeb1ABCDEF*
Am J Case Rep 2023; 24:e937687
BACKGROUND: Microbial keratitis is a major complication of keratoplasty that is associated with serious ocular sequalae if not adequately treated. The purpose of this case report is to present a case of infectious keratitis following keratoplasty caused by the rare microorganism Elizabethkingia meningoseptica.
CASE REPORT: A 73-year-old patient presented to the outpatient clinic complaining of a sudden decrease of vision in his left eye. The right eye was enucleated during childhood due to ocular trauma and an ocular prosthesis was placed in the orbital socket. He underwent penetrating keratoplasty 30 years ago for corneal scar and repeated optical penetrating keratoplasty for failed graft in 2016. He was diagnosed with microbial keratitis following optical penetrating keratoplasty in the left eye. Corneal scraping of the infiltrate showed growth of the gram-negative bacteria Elizabethkingia meningoseptica. Conjunctival swab of the orbital socket of the fellow eye was positive for the same microorganism. E. meningoseptica is a rare gram-negative bacterium, which is not part of the normal ocular flora. The patient was admitted for close monitoring and was started on antibiotics. He showed significant improvement after treatment with topical moxifloxacin and topical steroids.
CONCLUSIONS: Microbial keratitis is a serious complication following penetrating keratoplasty. An infected orbital socket could be a risk factor of microbial keratitis of the fellow eye. A high index of suspicion, along with timely diagnosis and management, may improve the outcome and clinical response and reduce the morbidity associated with these infections. Prevention of infectious keratitis is essential and may be achieved by optimizing the ocular surface and treating the risk factors for infection.
Keywords: Corneal Diseases, Corneal Transplantation, Keratitis, Keratoplasty, Penetrating
Infectious keratitis may be caused by bacteria, fungi, viruses, parasites, or a polymicrobial infection . There is an increased risk of microbial keratitis following penetrating keratoplasty. The incidence of microbial keratitis after optical penetrating keratoplasty varies from 1.76% to 7.4% in developed countries and from 11.9% to 25% in developing countries . Post-keratoplasty infectious keratitis is a diagnostic and therapeutic challenge. Bacteria have been reported to be the most common causative agents of infectious keratitis, with
A 73-year-old man presented to the outpatient clinic during a routine followup in June 2021. On presentation, the patient complained of a sudden decrease of vision in his left eye for the duration of 2 months. The right eye had been enucleated during childhood due to ocular trauma and an ocular prosthesis was placed in the socket. The patient had undergone optical penetrating keratoplasty 30 years ago due to a trachomatous scar. He had undergone combined extracapsular cataract extraction, posterior chamber intraocular lens implantation, and penetrating keratoplasty for mature cataract and for a failed graft that was performed in February of 2016. The medical history of the patient was negative. On examination, the visual acuity of the left eye was 20/200. The intraocular pressure of the left eye was 12 mmHg. Anterior segment examination of the left eye showed diffuse graft edema and inferior graft infiltrate involving the anterior stroma measuring 1.5×2 mm with an overlying corneal epithelial defect measuring 2×3 mm and adjacent neovascularization. The anterior chamber was deep, with a 0.8 mm white hypopyon (Figure 1A). Fundus examination was unremarkable. The right eye had a poorly fitted ocular prosthesis with yellowish discharge from the orbital socket.
The patient was admitted, and scraping of the corneal infiltrate was performed for the left eye and sent for microbiological investigation (Gram staining, Giemsa Staining, and microbiological culture). The corneal scraping samples were collected by using a Kimura platinum spatula and inoculated on blood agar, chocolate agar, Sabouraud dextrose agar, and thioglyco-late broth by using standard C-streak method. Gram-negative bacilli were detected on Gram staining. Cultures of the corneal smear showed prominent growth of gram-negative bacilli on blood agar and chocolate agar. The isolated organism was confirmed to be
In the current case, the patient had a history of repeated penetrating keratoplasty in his seeing eye and he was on anti-glaucoma medications. His advanced age accompanied by a poor ocular surface may have predisposed the eye to infection with this opportunistic organism. The infection of the right orbital socket was transmitted to the left seeing eye, which indicates that proper care of the orbital socket and ocular prosthesis is essential to prevent transmission of infection from an ocular prosthesis to the contralateral seeing eye, especially in cases where ocular immunity is compromised. The growth of gram-negative bacilli was observed in 2 solid culture media and Gram stain. The
Microbial keratitis is a serious complication following penetrating keratoplasty. Prevention of infectious keratitis is essential and may be achieved by optimizing the ocular surface and treating the risk factors for infection. A high index of suspicion and timely diagnosis and management may improve the outcome and clinical response and reduce the morbidity associated with these infections. This case highlights the occur-rence of keratitis in a corneal graft secondary to an infection of the fellow orbital socket with the unusual organism
FiguresFigure 1.. (A) Photo of the left eye showing the density of the corneal infiltrate with associated graft edema at presentation. (B) Photo of the left eye 2 weeks after treatment, with corneal scar, healed epithelial defect, and resolved hypopyon. (C) Photo of the left eye 2 months after treatment. The photo shows resolved graft edema with a faint superficial scar.
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