Late diagnosis of donor‐to‐host herpes infection in a descemetic deep anterior lamellar keratoplasty (dDALK) procedure for keratoconus: case report.

Purpose To report a case of donor herpetic infection after descemetic deep anterior lamellar keratoplasty (dDALK) using the big‐bubble technique in a patient with no previous history of herpes simplex virus type 1 (HSV‐1) infection. Methods A 39 year old man with a 15‐year history of keratoconus underwent an uncomplicated dDALK. Graft failure treated with excisional dDALK happened 3 times. Culture of failed donor corneas, bandage contact lens and stitches were tested for fungus and bacteria in all three explanted tissues. Polymerase chain reaction (PCR) for HSV‐1 DNA was performed only on the last failed corneal graft. Results Four weeks after intervention patient developed a primary graft failure with corneal melting. Emergency DALK procedure was performed. Cultures were negative for fungus and bacteria. Graft failure occurred again during the early postoperative period. Another DALK procedure was performed. Cultures were again negative in removed tissues. In eight days the patient developed a third graft failure with corneal melting, so that a new DALK procedure had to be performed. PCR was positive for HSV‐1 DNA. Systemic acyclovir prevented a recurrence of infection and at the 6‐month and 1 year follow‐up, no signs of corneal graft failure were detected. Conclusion HSV infection should be considered in the differential diagnosis with bacterial and fungal infection in early graft failure after DALK procedure. DALK allowed the repetition of corneal transplantation four times and provided enough endothelial cell density at 6‐month of follow‐up.