Early Onset Corneal Infections After Endothelial Keratoplasty Sahil Goel, MD (Presenting Author), Prashant Garg, MD *The authors have no financial interests to disclosure

Introduction: Interface Infections after DSAEK are often challenging- both diagnostically and therapeutically 1 Purpose: To Describe prevalance, etiology and risk factors of early onset (<6 weeks) post DSAEK infections. Also to evaluate various therapeutic options and their outcomes Setting: L V Prasad Eye Hospital, Hyderabad India 1) Nahum Y, Russo C, Madi S, Busin M.. Interface infection after descemet stripping automated endothelial keratoplasty: outcomes of therapeutic keratoplasty. Cornea Sep;33(9):893-8.

- This is a retrospective interventional case series done at a tertiary care hospital in India. - All patients undergoing Endothelial Keratoplasty (EK) from July 2008 to June 2014 were retrospectively analysed for early onset infections (<6weeks). - Eyes with isolated post operative endophthalmitis were excluded - Patients thus identified were studied for risk factors, etiology, management and long term outcome. Methods:

1) Medical management was successful only in one case of suture related surface infiltrates. 2) All other cases ended up with Therapeutic Penetrating Keratoplasty (TPK) 3) Lenticule removal was done in one patient with donor rim culture positive 4) Simultaneous Pars plana vitrectomy + intraocular antibiotics (PPV + IOAB) was done for patients with coexisting fulminant endophthalmitis Treatment strategies: Host Stroma only – Medical management Interface – Therapeutic PK/ Patch graft Lenticule only – Explant +/- Endoscraping

S. No.Causative Agent Visual Acuity Presenting Features Management Onset of Infection 1) Pseudomonas aurogenosa 20/20 Interface infiltrate (1mm)TPK41 Days 2) P. aeruginosa 20/30 Temporal wound site (suture related)Medical mg10 Days 3) P. aurogenosa 20/126 Stromal infiltrates (Ring) Suspected endophthalmitisTPK+PPV+IOAB17 Days 4) Pseudomonas sp. FC 1m ? Stromal infiltratesTPK39 Days 5) P. aeruginosa HM Stroma + lenticule Suspected endophthalmitisTPK4 Days 6) P. aurogenosa PL+ (Phthisis) Hypopyon + Fulminant endophthalmitis TPK + IOAB + IOL explant2 Days 7) P. aurogenosa No PL (Phthisis) Stromal infiltrate + Fulminant endophthalmitisTPK + PPV + IOAB2 Days 8) Enterobacter cloace N/A Stroma + lenticule Lenticule removal + IOAB1 Days 9) Staph. aureus 20/25 Interface infiltratesTPK4 Days 10) Corynebacterium striatum 20/50 Interface infiltratesTPK3 Days 11) Brevibacterium sp. FC 1m Interface (Pin head)TPK5 Days 12) Aspergillus flavus PL+ Stromal (Venting related)+ InterfaceTPK8 Days 13) No organism, PCR Fungus –ve 20/30 Interface + lenticuleTPK8 Days

Results: 1) With a mean follow up of 24 months (Range 3-73 months) none of the eyes had recurrence of infection at last follow up 2) Graft clarity was maintained in 6 of 13 cases at last follow up 3)Majority of early onset infections were caused by Multi-Drug Resistant (MDR) Pseudomonas 4) Of the 7 MDR cases 2 were sensitive only to colistin and 5 to imipenem and piperacillin only 5) None of the eyes transplanted with fellow donor developed infection related complication

AB C E D CASE 12: Fig.(A) Right eye 8 days after Phaco + PCIOL + n-DSAEK for failed therapeutic PK. (B) Magnified view shows infiltrates (*) surrounding upper right venting incision. (C) Corneal scraping showed septate hyaline fungal filaments. After 1 week of failed topical anti-fungal therapy therapeutic penetrating keratoplasty was done. (D) Hematoxylin and eosin stain of half corneal button showing epithelial downgrowth (arrow) with activated keratocytes in area of venting incision. (E) In area of surrounding infiltrates septate hyaline fungal filaments (dark arrow) are seen using Grocott's methenamine silver stain. *

Visual outcome: 1 ) All 4 cases of suspected endophthalmitis had poor visual outcome, including 2 phthisical eyes. 2) Of the remaining 8 cases with long term follow up, 5 grafts survived at last follow up, with best spectacle corrected visual acuity of 20/50 or better 3) 5 of 7 patients presenting within 5 days of surgery had final visual acuity of 20/1200 or less 4) 2 patients with larger than 10 mm graft had final visual acuity of hand movements

Causative Agent Visual Acuity Presenting Features ManagementRisk FactorsOnset of Infection Candida glabrata 1 20/25InterfaceTPKDonor culture30 days Candida albicans 2 20/40InterfacePatch GraftDonor culture41 days Candida parapsilosis 3 20/40Stroma + Vitreous TPK + PCIOL removal Venting Incision 35 days Aspergillus fumigatus 4 20/40Lenticule + Interface TPK-120 days Candida albicans 2 20/50InterfaceLenticule extraction + Repeat DSAEK Donor culture39 days Staph. aureus 4 20/60StromaTPK-35 days Candida albicans 1 No PLInterfaceTPK-21 days Candida albicans 5 No PLLenticuleTPKDonor culture7 days 1) Lee WB et al. Interface fungal keratitis after endothelial keratoplasty: a clinicopathological report. Ophthalmic Surg Lasers Imaging Apr 14;42 2) Kitzmann AS et al. Donor-related Candida keratitis after Descemet stripping automated endothelial keratoplasty. Cornea Aug;28(7): ) Chew AC, Mehta JS et al. Fungal endophthalmitis after descemet stripping automated endothelial keratoplasty-a case report. Cornea Mar;29(3): ) Sharma N et al. Microbial keratitis after descemet stripping automated endothelial keratoplasty. Eye Contact Lens Sep;37(5): ) Koenig SB et al. Candida keratitis after descemet stripping and automated endothelial keratoplasty. Cornea May;28(4): Review of Literature

Conclusion: 1) Unlike western literature showing Fungus as predominant cause of Interface infections, our series had for having multi drug resistant Pseudomonas as the predominant cause of post endothelial keratoplasty corneal infections. 2) Early presentation after surgery, coexisting endophthalmitis, large sized graft, delayed in therapeutic penetrating keratoplasty were risk factors for poor visual outcome in cases of post DSAEK infections in our series.