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EW CORNEA 74 September 2016 by Vanessa Caceres EyeWorld Contributing Writer donor tissue," Dr. Amescua said. Additionally, a small inoculum may lead to an infiltrate in a protect- ed environment of the graft-host interface. Small interface infiltrates can be misdiagnosed as debris, and then it will take weeks or months for a clinically significant infection to develop, he added. The routine use of topical ste- roids after EK may promote and in- crease the severity of fungal keratitis. MD, Elizabeth Talbot, MD, and the New Hampshire Department of Health and Human Services) found in a literature review 15 distinct case reports after Descemet's stripping automated endothelial keratoplasty (DSAEK). 2 However, physicians at Dr. Amescua's program are seeing a small increase in the number of cases. The cause of infection can vary. "Most of the infections happen at the time of surgery from contamina- tion from the patient ocular surface flora or from contaminated corneal Infection experiencing small rise; role of donor rim culturing debated F ungal keratitis after endo- thelial keratoplasty (EK) may be uncommon, but ophthalmologists must stay aware of its signs and caus- es, as it can be a difficult condition to manage. The signs of fungal keratitis after EK may sound similar to other infec- tions. "It's diagnosed with clinical examination, which may be char- acterized by white infiltrates with indistinct margins," said Edmund Tsui, MD, ophthalmology resident physician, New York University Langone Medical Center, New York. "Patients may also complain of pain, redness, and decreased vision. Obtaining clinical cultures will aid in the identification of the fungal organism involved and can help guide treatment." Guillermo Amescua, MD, as- sistant professor of clinical ophthal- mology, Bascom Palmer Eye Insti- tute, Miami, further explained the signs of fungal keratitis. "Patients usually present with multifocal infiltrates in the deep corneal stroma and graft-host interface weeks to months after the surgical interven- tion," he said. Because of the infection's loca- tion, it can be difficult to obtain a microbiological specimen to con- firm diagnosis, Dr. Amescua said. "If the corneal donor rim was sent for surveillance culture and there is positive fungal growth, a diagnosis can be established. Unfortunately, corneal donor rims are not always sent for surveillance cultures." Another option is obtaining anterior chamber fluid for culture or passing a deep suture in the area of interest and sending it for microbio- logical analysis, Dr. Amescua said. Infection rates and causes Fungal keratitis is actually a rare complication of lamellar transplan- tation. A 2013 Eye Bank Association of America (EBAA) report found a rate of only 0.022% in cases from 2007 to 2010. 1 A report from Dr. Tsui and colleagues (senior author Michael Zegans, MD, Erin Fogel, Uncommon and not easy: Diagnosing and treating fungal keratitis after EK F ungal infections are a dreaded occurrence in the cornea and anterior segment given the difficulty in erad- icating the disease. Luckily, these are rare. It is rarer still for fungal keratitis to develop after endothelial keratoplasty surgery. Corneal storage media does not contain any anti-fungal medication, and after surgery, patients are typically not treated with anti-fungal prophylaxis. Routine culturing of donor corneal rims is not performed at all centers, which is controversial. A high level of suspicion is required for an early diagnosis, and success with treatment can be challenging. In this month's "Cornea editor's corner of the world," Edmund Tsui, MD, and Guillermo Amescua, MD, discuss their experience with the diagnosis and management of fungal infections after endothelial keratoplasty. Clara Chan, MD, FRCSC, FACS, Cornea editor Cornea editor's corner of the world continued on page 76 A 67-year-old male s/p DSEAK presented a few weeks after a non-complicated surgical intervention. He was diagnosed with Candida albicans. The patient had rapid progressive infection after his visit and had a therapeutic corneal transplant, removal of intraocular lens/ capsule complex, and pars plana vitrectomy. This photo shows a clear corneal transplant a year later. The patient has vision of 20/25 with an aphakic contact lens. Source: Guillermo Amescua, MD

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