Eyeworld

87 EW CORNEA October 2018 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer graft was contacted, and they soon confirmed the contaminated, infect- ed medium. On day 22, the local tissue bank could isolate a nontuber- culous atypical mycobacterium from the transport medium. Nontuberculous mycobacteria are ubiquitous in the environment, found in soil, water, and aquatic animals. They cause opportunistic infections among both immuno- compromised and immunocompe- tent individuals and have a broad spectrum of virulence. A subset of mycobacteria has been characterized as "rapidly growing" and is implicat- ed in infections of catheters, post- LASIK, skin and soft tissue, and the A mycobacteria- contaminated donor cornea can set transplantation surgery into a tailspin C ontamination during the surgical process is always a real possibility. Present- ing a case of cornea graft contamination at the 22nd ESCRS Winter Meeting, Minh Tri Hua, MD, UZ Leuven, Belgium, reported on an incident of contam- ination that originated well outside of the operating room. Day 1: Uncomplicated DMEK surgery In March 2017, a 76-year-old male patient underwent Descemet's membrane endothelial keratoplas- ty (DMEK) for Fuchs' endothelial dystrophy. The graft was prepared by the surgeon in the OR, and the surgery was completed without any undo complications, including a thumbs-up on the day 5 postopera- tive follow-up examination. The local tissue bank reached out on postoperative day 17 to inform the surgical center that an aerobic culture from the transport medium had turned positive. The foreign eye bank that provided the lungs. Rapidly growing mycobacte- ria are gaining emerging importance in both sporadic infections and outbreak settings. 1 Day 25: Interface infiltrates On postoperative day 25, the pa- tient had an uncorrected visual acu- ity (UCVA) of 0.6 logMAR. Dr. Hua and his colleagues called the patient back for an examination earlier than scheduled. The patient exhibited no symptoms at this point. A slit lamp exam revealed several cor- neal infiltrates, which were at first misdiagnosed. The infiltrates were situated between the graft and the corneal stroma. Dr. Hua started the patient on moxifloxacin 4x/day and tobramycin/dexamethasone 4x/day. He did not stop the corticosteroid regimen at that point, although he later would. Five days later, the infiltrates were seen to be getting worse (post- operative day 30), but visual acuity was as yet unaffected by the infec- tion, with a UCVA of 0.6 logMAR. "The infiltrates were increasing, getting worse and bigger. Optical co- herence tomography (OCT) demon- strated the location of the infiltrates perfectly between the graft and the stroma at the interface," Dr. Hua said. Azithromycin per os 500 mg/d for 3 days then 250 mg/d was added to the patient's treatment regimen. Dr. Hua referred the patient to an internist who replaced azithromycin with clarithromycin per os 500 mg 2x/day, which was recommended for 6 months along with amikacin eye drops 8x/day. The treatment of nontubercu- lous mycobacteria is lengthy and varies by species. Macrolide-based regimens using agents such as clarithromycin can be costly, induce intolerance, and cause potential toxicity in patients. In patients fail- ing standard therapy, the addition of moxifloxacin to a multi-drug regimen can improve treatment out- comes, although clinical evidence is sparse. 2 Atypical mycobacterial interface keratitis after DMEK continued on page 89 Presentation spotlight The corneal infiltrates grew along the graft interface. They began as ill-defined whitish spots and became whiter and sharper over time. Source: Minh Tri Hua, MD Day 51 Day 137

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