Recurrent Fungal Keratitis Following Penetrating Keratoplasty: An Unusual Source of Infection

Report of a Case. A 75-year-old woman visited us in 2007 with left ocular discomfort for 1 month. She had previous bilateral penetrating keratoplasties (for the right eye in 1998 and for the left eye in 2004) for decompensated Fuch’s endothelial dystrophy. She had undergone trabeculectomy with mitomycin C (in 2006) and was using topical dexamethasone sodium phosphate, 0.1%, daily in the left eye. Her medical history included uterine carcinoma, treated Hodgkin lymphoma, pulmonary embolism, emphysema, hypertension, ischemic heart disease, hyperthyroidism, and renal failure. Visual acuity was 6/12 (20/40) OD with clear corneal graft and 6/36 (20/100) OS. Examination of the left eye revealed a deep stromal infiltrate measuring 2 1.3 mm and with hypopyon (Figure, A). Steroid eyedrops were temporarily stopped, and treatment with cefuroxime sodium, 5%, and gentamicin sulfate, 0.3%, was commenced. Anterior chamber tap and corneal biopsy yielded a heavy growth of C parapsilosis. The treatment regimen was changed to intensive topical fluconazole, 0.2%, ofloxacin, and oral voriconazole (400 mg loading followed by 200 mg twice daily). Topical dexamethasone was reintroduced owing to evidence of rejection at day 7 and was gradually tapered as the abscess and graft edema resolved over the following 2 months. Keratitis recurred 2 months after discontinuing antifungal agents (Figure, B). Empirical treatment with fluconazole, 0.2%, and oral itraconazole, 100 mg twice daily, was commenced. Gentamicin, 1.5%, and cefuroxime, 5%, were added, and itraconazole was changed to voriconazole as the keratitis progressed