I wish I hadn’t done that: Denial ain’t just a river in Egypt
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This column is the latest article in the ongoing series “I wish I hadn’t done that.” Past submissions can be read here.
Full-thickness corneal transplants are becoming rarer in the United States, largely because of the overwhelming success of lamellar procedures, especially DSAEK and DMEK.
For these latter operations, the most feared postoperative complication might be fungal keratitis, which is usually disastrous and always necessitates immediate removal of the implanted graft.
Last year, I made the fateful decision to try a penetrating keratoplasty on a 26-year-old patient with advanced keratoconus and counting fingers vision. (The original plan was a deep anterior lamellar keratoplasty, but after an intraoperative perforation of Descemet’s membrane, the backup plan of PK was initiated.) Aside from converting to PK, the surgery was otherwise uneventful, and the immediate postoperative appearance of the eye was normal.
Three days later, a positive fungal culture resulted from the donor tissue (“rare yeast”), which was speciated into Candida glabrata several days later. The occasional positive fungal culture is not altogether unheard of, and statistically, the vast majority of these positive cultures (greater than 90%) do not result in clinically evident infection. As a result, I kept a watchful eye on the patient but otherwise initiated no special treatment.
One week postoperatively, the patient called the office complaining of redness and discomfort. On exam, she displayed 2+ injection and anterior chamber reaction. I considered the possibility of a fungal infection, but the patient’s cornea was clear with no sign of an infiltrate, and her vision had already improved to 20/80 uncorrected. I thought that perhaps the more likely problem was postoperative inflammation or an early allograft reaction, so I increased her steroids (prednisolone acetate 1%) from four to eight times daily.
A week later, the patient felt much improved. Her operated eye was completely white and comfortable, and her vision had further improved to 20/60. However, there was an eerie 4+ cell and 0.5 mm hypopyon. These findings were impossible to ascribe to inflammation, and the reality of fungal infection was impossible to deny. The graft was infected — no other conclusion could be drawn. Still, the donor graft looked pristine. It was crystal clear, the sutures were perfect, and the patient’s vision was good and improving. The eye was comfortable, and the patient was happy. Something had to be done, but what?
Here is where the big mistake happened. I decided to do the “conservative” thing and bring the patient to the operating room for an aqueous tap/culture and intravitreal injection of an antifungal (amphotericin). On the operating room table, I admired the clarity and shape of the graft. But immediately after I made my paracentesis, a thin, wispy, greenish-white hypopyon seeped out from the inferior angle. This was not a healthy eye. I delivered my intravitreal injection, and the operation was over, in all of 5 minutes.
The next day, the eye looked like a bomb had gone off. There was a 50% hypopyon, visible from across the room, and the patient had hand motion vision. The eye was red, inflamed and miserably uncomfortable. Things had become catastrophic. The only normal-appearing thing about the eye was the graft, which was still completely clear, without any visible infiltrate.
But now there was no choice — we made an emergency trip back to the operating room that day to replace the graft. This time, day 1 postoperatively was an obvious improvement, with no visible hypopyon. Oral ketoconazole and topical amphotericin eye drops were initiated, and for a week, topical steroids were held to avoid immunosuppression. After 2 months, the antifungals were discontinued, and after 4 months, the eye looked completely benign, like nothing had ever happened.
Mercifully, there was no recurrence of the infection, and replacing the graft was curative. But I learned the hard way the critical importance of acting with maximum hostility and aggression to combat transplant-related fungal keratitis, even in the face of a clear cornea, a comfortable eye and a happy patient. The key mistake was not replacing the graft immediately once the infection became clinically evident. The “minimally interventionist” strategy was a half measure in the face of an impending catastrophe, and it was a miracle that I got a second shot to do what I should have done in the first place.
- For more information:
- Jack S. Parker, MD, PhD, of Parker Cornea in Vestavia Hills, Alabama, can be reached at jack.parker@gmail.com.
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