Eyeworld

SEPTEMBER 2023 | EYEWORLD | 55 C Contact Lee: wblee@mac.com Tu: etu@uic.edu Reference 1. Fontana L, et al. Interface infec- tious keratitis after anterior and posterior lamellar keratoplasty. Clinical features and treatment strategies. A review. Br J Ophthal- mol. 2019;103:307–314. Relevant disclosures Lee: Dompe, Glaukos, Sun Pharma Tu: None the risk. Post-surgical prophylaxis with antifun- gals has also been advocated but with minimal supporting evidence as to efficacy, medication, route, and dosing." Dr. Lee said that eye banks have provided the most effective way to prevent infections by changing the way they prepare donor tissue. "The Eye Bank Association of America has mandated that all tissues prepared for cornea transplantation undergo a double betadine prep, meaning the tissue is treated with betadine for a set period of time after it is procured, rinsed away, then another betadine exposure is applied to the tissue for a second treatment," he said. "In addition, surgeons can now have the eye bank add antifungal medication to the tissue storage media." Once an interface infection is identified, patients should be started on topical treatment geared to the particular organism that was iden- tified, Dr. Lee said. If it is a Candida infection, topical and oral antifungal medication should be started, along with consideration of intravitreal antifungal treatment. Some surgeons advocate interface injections of antibiotics or antifungals toward the infected area of the cornea. Dr. Lee said that removal of the infected tissue is the next step. "For a Descemet's mem- brane endothelial keratoplasty case, removal of the tissue should include intracameral antibi- otic or antifungal injections," he said. "If the infection is trapped in the interface and has not spread to the anterior chamber, a therapeutic keratoplasty may be warranted in a case of anterior lamellar keratoplasty or Descemet's stripping endothelial keratoplasty." Additionally, Dr. Lee said that cultures of tissue or media at the time of surgery can be a useful guide for knowing what organism is present when an infection occurs. "The diag- nostic dilemma remains what to do when you get a positive rim culture, as not all positive rim cultures progress to infection," he said. Some surgeons prefer to start treatment with anti-in- fective agents as soon as a positive rim culture is reported while other surgeons do not treat and just watch the patient closely, he said, adding that no definitive treatment paradigm has been developed at this point. Dr. Tu said that when treating these infec- tions, topical and systemic antifungal treatment alone is associated with a high failure rate. Success has been reported with intrastromal injection, penetrating keratoplasty, and antifun- gals in conjunction with total or partial removal of the graft, he said. Post-lamellar keratoplasty infections can have devastating outcomes with limited but potentially successful therapies, Dr. Tu said. Infections are rare but more common than with penetrating keratoplasty surgery. With limited clinical evidence for optimal management, prac- tices should keep these factors in mind when deciding what interventions are appropriate and cost effective, he said. Interface infection after DMEK with Candida species Source: W. Barry Lee, MD

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