Outcome of therapeutic keratoplasty in fungal keratitis

Sonika Gupta, MS

Assistant Professor,

GMCH, Chandigarh, India

Author has no financial interest

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.

Cases of fungal keratitis

Feathery margins Fungal plaque with hypopyon

Infitrates with pigmentation

Corneal abscess

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.

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.

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%).

Isolates

5%

50%

36%

9%

Aspergillus

Fusarium

Candida

Curvularia

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).

Clear graft after TPKFungal corneal abscess

Complications after TPK in fungal keratitis

0

2

4

6

8

10

12

no. of cases

complications

persistentepithelialdefect

Reinfection

Glaucoma

Rejection

primary graftfailure

Complications after TPK in fungal keratitis

Graft infectionPersistent epithelial defect

Graft failure

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%.

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.