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    Why infections related to PK require intense vigilance

    Case study highlights risks in contact lens-related Pseudomonas corneal ulcer

    Baltimore—Infections associated with penetrating keratoplasty (PK) require careful monitoring and an examination into the cause of the infection, said Bennie H. Jeng, MD.

    Specific types of infection include microbial keratitis, endophthalmitis, recurrence of viral infection, and transmission of infections from the donor, said Dr. Jeng, professor and chairman, Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore.

    To highlight infection risks related to PK, Dr. Jeng shared the case of a 53-year-old woman treated for a contact lens-related Pseudomonas corneal ulcer in the right eye. After the infection cleared, the patient developed a new infiltrate that the referring ophthalmologist thought looked a little different.

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    Although culturing identified it as fungus, its specific species could not be pinpointed. She was started on hourly voriconazole 1% and natamycin for recalcitrant infection.

    The infection still progressed, and a deep anterior lamellar keratoplasty was performed to debulk the infection. Postoperatively, she was started on prednisolone acetate 1% and gatifloxacin.

    Still, the patient’s infection persisted, and she was referred to the office of Dr. Jeng and colleagues. Despite aggressive therapy including topical, intracameral, and oral antifungal agents, therapeutic PK was required to treat the infection.

    “Unfortunately, the patient had started herself on topical steroids immediately postoperatively,” Dr. Jeng said. “So, as you’d expect, there was recurrence of the infection by day six.”

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    The infection still wasn’t controlled with intracameral injections of antifungals. Five days later, a limbus-to-limbus PK was performed along with irrigation of the anterior chamber with antifungals.

    Postoperatively, the patient was put on oral antifungals.

    The infection was “surprisingly sensitive” to voriconazole and amphotericin, Dr. Jeng said. “I think the infection was hiding deep in the cornea.”

    The limbus-to-limbus graft eventually failed, and a 7 mm PK and cataract extraction was performed. Ultimately, she was regrafted once more, but at four years after original presentation, the patient’s best spectacle-corrected visual acuity was 20/25.

    Dr. Jeng said that his case touched upon a series of risks associated with infection in the setting of PK.

    Microbial keratitis

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