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BRIEF COMMUNICATION
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 95-97

Deep anterior lamellar keratoplasty in dematiaceous keratomycosis


Department of Cornea, H. V. Desai Eye Hospital, Pune, Maharashtra, India

Date of Submission16-Dec-2014
Date of Acceptance03-Feb-2016
Date of Web Publication9-Jun-2016

Correspondence Address:
Shilpa Ajit Joshi
Flat No. 6, Siddh Smruti Apartments, Plot No. 35, Ashok Nagar, Range Hills Road, Pune - 411 007, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.183721

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  Abstract 

Deep anterior lamellar keratoplasty is a technique which has been used effectively to treat anterior stromal corneal opacities, with the obvious benefit of preserving host endothelium. This report documents its use in a case of dematiaceous keratomycosis resistant to conservative management. Therapeutic penetrating keratoplasty, although a gold standard, has a high risk of rejection and poor graft survival. In our patient, careful case selection and meticulous dissection ensured elimination of infection, restoration of vision, and absence of recurrence of infection.

Keywords: Deep anterior lamellar keratoplasty, dematiaceous keratomycosis, graft survival, therapeutic penetrating keratoplasty


How to cite this article:
Joshi SA, Sharma NS, Deshpande M. Deep anterior lamellar keratoplasty in dematiaceous keratomycosis. J Clin Ophthalmol Res 2016;4:95-7

How to cite this URL:
Joshi SA, Sharma NS, Deshpande M. Deep anterior lamellar keratoplasty in dematiaceous keratomycosis. J Clin Ophthalmol Res [serial online] 2016 [cited 2020 Sep 20];4:95-7. Available from: http://www.jcor.in/text.asp?2016/4/2/95/183721

Dematiaceous fungi are saprophytic pigment producing fungi found mostly in soil and decomposing vegetative material. The pigmented plaque infiltrate commonly seen in keratomycosis due to this group of fungi consists of surface colonization of pigmented fungal filaments and has been related to melanin metabolism.

In India, the incidence of fungal keratitis is nearly 40-50% of all infective keratitis [1] with dematiaceous fungal keratitis being the 3 rd most common agent (10-31%) in fungal isolates after Fusarium and Aspergillus. [2] Commonly reported dematiaceous fungal isolates are Curvularia and Alternaria.

Usual treatment regime consists of topical antifungal drops (commonly natamycin and/or voriconazole), combined with superficial keratectomy and plaque removal. [3] Therapeutic penetrating keratoplasty (PK) is usually undertaken for resistant or deep keratomycosis, with variable success rate due to high risk of rejection. [4] We report a case of pigmented fungal keratitis with deep stromal involvement, which was managed with deep anterior lamellar keratoplasty (DALK).


  Case Report Top


A 50-year-old female presented to us with a history of trauma inflicted by vegetative matter to her left eye (LE), followed by pain, redness, tearing, and progressive diminution of vision of 2 weeks duration. She had been treated elsewhere with local antibiotics. Her best-corrected visual acuity was 6/9 in the right eye and 2/60 in the LE, respectively on Snellen chart. The right eye was normal but for early cataractous changes. The LE had a diffuse conjunctival injection with circumcorneal congestion, and a centrally located (8 mm × 7.5 mm), diffuse, elevated, and leathery brown pigmented plaque on the corneal surface with brownish anterior stromal infiltrates [Figure 1]. There was anterior chamber reaction of Grade 1 with an immature cataract. The posterior segment could not be visualized clearly due to media opacity.
Figure 1: Dematiaceous fungal plaque

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Corneal scraping on potassium hydroxide (KOH) mounts demonstrated multiple fungal hyphate filaments with pigmented walls along with few inflammatory cells.

A diagnosis of dematiaceous keratomycosis was made, a superficial keratectomy was done, and treatment started with intensive antifungal eye drops (natamycin 5%), in adjunct with cycloplegic and lubricant eye drops. During treatment, along with debridement to reduce fungal load, topical voriconazole 1% was added and also injected intrastromally twice. However, the patient did not respond to the treatment, and there was a recurrence of the pigmented plaque, but without underlying liquefaction necrosis of stroma, or abscess formation [Figure 2].
Figure 2: Recurrence after superficial keratectomy

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Following the poor response to medical treatment for 2 weeks, we decided to perform a DALK, with preparation to convert into PK, if needed. Partial keratectomy was done to excise the plaque and deep stroma. Since the fungal plaque was limited to subepithelial and anterior stromal layer of the cornea, with no suppuration of the stroma, intraoperatively creating a smooth plane of dissection was possible. Meticulous examination of residual stromal bed was done to rule out the possibility of any infiltration. It was possible to create a "big bubble" by injecting air intrastromally. The separated stroma was excised bearing the descemets, thus, eliminating the possibility of retention of infective foci in the host bed. Graft size was 8.5 mm × 8.0 mm. There were no intraoperative complications.

Postoperatively, topical antifungals were given for 3 weeks; loteprednol was added later. There was no recurrence of infection and no occurrence of a rejection reaction until her last follow-up which was 4 months postoperative [Figure 3]. Visual acuity improved to 6/36 with an immature cataract.
Figure 3: Four months postoperative -deep anterior lamellar keratoplasty

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  Discussion Top


The above case was one among nine patients diagnosed with dematiaceous keratomycosis in our cornea clinic, all of whom had the typical macroscopic pigmented plaque presentation with diagnosis confirmed by KOH mount preparation. In our clinical setting, the diagnosis and institution of treatment depended on KOH smear. The culture was performed for the purpose of confirmation and documentation. In our series, good results were obtained with superficial keratectomy combined with aggressive antifungal medications, but deep or nonresponsive dematiaceous keratomycosis in two cases required PK in one [5],[6] and DALK in another. PKs have a higher rate of endothelial rejection as the Descemet's membrane is also replaced in it. Lamellar keratoplasty has been reported with variable success rates, [7] with a recurrence of infection due to inadequate removal. A PK is a standard technique for infective keratitis not responding to medical treatment, where the goal of surgery is the removal of the quantum of infection and maintaining ocular structural integrity. However, DALK can be considered a good alternative to therapeutic/tectonic PK in nonfulminant infective keratitis, localized to anterior and mid stroma. It has been reported in bacterial, fungal, and Acanthamoeba keratitis. [8] It has a lesser risk of intraocular entry of infectious organisms at the time of surgery and the potential for improved graft survival rates due to less risk endothelial rejection and failure. However, DALK is to be reserved for selected cases only, with PK remaining the gold standard for most cases.

To the best of our knowledge, this is the first report of DALK done for a pigmented fungal ulcer. There was a recurrence of plaque in spite of repeated superficial keratectomies. Since posterior stroma was not involved, we thought of doing DALK. Recurrence despite intensive local treatment and superficial keratectomies, along with uninvolvement of the posterior stroma, were ideal indications for opting for DALK. The "big bubble technique" created a cleavage plane which helped in the complete removal of infected stromal layers. Furthermore, Descemet's bearing dissection helped in getting the optically clear interface in our case. Thus, surgery achieved the purpose of elimination of infection and restoration of the optical axis. The adequate dissection at the plane of the Descemet's membrane ensured prevention of recurrence, without the risks and limitations of a penetrating procedure.

DALK can arrest the infective process, and provide useful vision with few complications in judiciously selected cases of dematiaceous keratomycosis refractory to local treatment with superficial keratectomy.

Acknowledgement

We thank Dr. Pranav More, (Medical Director, Eye bank, H. V. Desai Eye Hospital) and our eye bank staff - Mr. Satish Kurpad and Mrs. Urmila Prabhane for their help and support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gopinathan U, Sharma S, Garg P, Rao GN. Review of epidemiological features, microbiological diagnosis and treatment outcome of microbial keratitis: Experience of over a decade. Indian J Ophthalmol 2009;57:273-9.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Ganguly S, Salma KC, Kansakar I, Sharma M, Bastola P, Pradhan R. Pattern of fungal isolates in cases of corneal ulcer in the western periphery of Nepal. Nepal J Ophthalmol 2011;3:118-22.  Back to cited text no. 2
    
3.
Garg P, Vemuganti GK, Chatarjee S, Gopinathan U, Rao GN. Pigmented plaque presentation of dematiaceous fungal keratitis: A clinicopathologic correlation. Cornea 2004;23:571-6.  Back to cited text no. 3
    
4.
Forster RK, Rebell G, Wilson LA. Dematiaceous fungal keratitis. Clinical isolates and management. Br J Ophthalmol 1975;59:372-6.  Back to cited text no. 4
    
5.
Sengupta S, Rajan S, Reddy PR, Thiruvengadakrishnan K, Ravindran RD, Lalitha P, et al. Comparative study on the incidence and outcomes of pigmented versus non pigmented keratomycosis. Indian J Ophthalmol 2011;59:291-6.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Garg P, Gopinathan U, Choudhary K, Rao GN. Keratomycosis: Clinical and microbiologic experience with dematiaceous fungi. Ophthalmology 2000;107:574-80.  Back to cited text no. 6
    
7.
Xie L, Shi W, Liu Z, Li S. Lamellar keratoplasty for the treatment of fungal keratitis. Cornea 2002;21:33-7.  Back to cited text no. 7
    
8.
Anshu A, Parthasarathy A, Mehta JS, Htoon HM, Tan DT. Outcomes of therapeutic deep lamellar keratoplasty and penetrating keratoplasty for advanced infectious keratitis: A comparative study. Ophthalmology 2009;116:615-23.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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