1. Outcome of therapeutic keratoplasty in fungal keratitis Sonika Gupta, MS Assistant Professor, GMCH, Chandigarh, India Author has no financial interest

2. Purpose of Study To study the outcome of therapeutic penetrating keratoplasty (TPK) in fungal keratitis, which is a major cause of corneal blindness in our set-up.

3. Cases of fungal keratitis Feathery margins Fungal plaque with hypopyon Infitrates with pigmentation Corneal abscess

4. Methods A prospective database on 44 therapeutic keratoplasties in 44 patients of fungal keratitis recorded the following data- demographic details on age and gender of the patient, indication for surgery, size of donor and recipient bed causative organism and complications. Indications for surgery -fungal keratitis not responding to maximal medical therapy, desmetocele with infiltrates, or a perforation of more than 2 mm in the presence of active inflammation. All patients underwent TPK by a similar method -a donor button oversized by 0.5 mm and 16 bites of interrupted sutures with 10-0 monofilament nylon.

5. Methods Minimum follow-up period was 1 year. Excised host cornea was sent for microbiologic and histopathologic examination. Outcomes were evaluated in terms of anatomical success, graft clarity and visual acuity. Effect of graft size, causative organism and perforation on the final outcome was analyzed. Statistical analysis: Chi-square tests were performed for categorical variables. A p-value of 0.05 was considered significant.

6. Results Mean age of patients was 45.98 ± 18.23 years (range 14-80 years). 30 males, 14 females. Thirteen eyes had perforation at presentation. Mean graft diameter was 9.0 mm (range 7.5 -11 mm) Isolates identified were Aspergillus (50%), Fusarium (36%),Candida (9.0%) and Curvularia (4.5%).

7. Results Anatomical success seen in 42 eyes (95.4%). Grafts in 18 eyes (40.9%) remained clear during follow-up. Visual acuity ≥ 20/200 achieved in 9 eyes (20.4%). Graft size, species of organism and perforation did not significantly affect anatomical success and visual outcome. Graft size significantly correlated with graft clarity (p= 0.0016 chi- square test). No correlation was found between perforation and organism species with graft clarity (p=0.39).

8. Clear graft after TPKFungal corneal abscess

9. Complications after TPK in fungal keratitis

10. Graft infectionPersistent epithelial defect Graft failure

11. Discussion Xie et al Br J Ophthalmol 2001 Retrospective analysis of 108 cases Corneal grafts clear in 86 eyes (79.6%). Complications: graft rejection (29.6%), reinfection (7.4%), cataract (4.6%). Vision better than 20/60 was seen in 26.8% of eyes. Ti et al American J Ophthalmol May 2007 TPK in fungal keratitis n=31 Fusarium sp.(32.3%) predominant causative organism. One year therapeutic survival 72.4%.

12. Conclusion TPK is successful in maintaining the ocular integrity in most eyes with fungal keratitis. Lower number of clear grafts in our study could be due to Delay in presentation by the patient leading to delayed surgical intervention Lack of availability of good quality donor tissue. Inadequate compliance with follow-up.