Eyeworld

33 EW CORNEA January 2018 by Maxine Lipner EyeWorld Senior Contributing Writer OK." The patient's final best specta- cle acuity was 20/60, Dr. Thompson noted. "It's disappointing that the vision was worse than it was before he had the surgery, but given the infection, it could have been much worse than it turned out to be," he said. Future cases Dr. Thompson said the case adds to the literature on this. "If this hap- pens to someone else, it's one case saying that medication alone did not work and the patient required surgery," he said, adding that other practitioners will do what they think is best, but hopefully they will report the results so that after enough cases have been reported, others will know how likely it is that patients will require surgery. Dr. Thompson said he would have removed the infectious grafts sooner if he had seen a prior case like this one published. From a broader perspective, one concern is that eye banks don't use any antifungal medical in the storage solution for transplants. "I don't know why they don't," Dr. Thompson said. "I'm guessing that it's more FDA approval of adding something to the storage solution and would require extensive study." These rare infections could be pre- vented if there was a way of placing antifungal medication on the donor tissue before this was used. Dr. Thompson hopes that prac- titioners come away from the case with a better understanding of what to do when faced with a fungal in- fection with a DMEK transplant. "I think the take-home message is that if you have a transplant with a do- nor rim that grows fungus and you have an eye that starts to show clin- ical signs of infection, you should remove the graft," he concluded. EW Reference 1. Thompson M, et al. First reported case of donor related Candida endophthalmitis after Descemet membrane endothelial keratoplasty. Open Ophthalmol J. 2017;11:117–121. Editors' note: Dr. Thompson has no financial interests related to his comments. Contact information Thompson: 100mjt@gmail.com Determining whether to pro- ceed medically or surgically at that point was a toss-up when looking at published cases. "There are cases where patients did fine with just medical treatment, and there are cases where patients did not do fine with medical treatment and needed surgical treatment," Dr. Thomp- son said, adding that there were no fungal DMEK cases specifically to be found in the literature. He speculated that because a DMEK is so much smaller than a DSEK, with the amount of infectious material being transplanted likewise small- er, the chances of treating it with medicine would be better. This was the approach he took, but unfortu- nately, the infection continued to get worse. By day 19, Dr. Thompson needed to go in and remove the donor cornea. He continued to treat the patient with multiple injections of antifungal medications and to culture the eye. "Eventually, after several injections, the cultures turned negative, and the infection was no longer seemingly present," Dr. Thompson said. "We put a new donor cornea in and it took a long time, but the patient eventually did risk of resulting in an infection, Dr. Thompson said. While eye banks have extensive criteria to screen donor tissue, the corneas themselves are not sterile. "Even though the eye bank harvests them using a sterile surgical tech- nique and they're stored in a solu- tion that has antibiotic in it, there is no way to sterilize a cornea," Dr. Thompson said. "The solution that they're stored in is called Optisol-GS [Bausch + Lomb, Bridgewater, New Jersey], which has two antibiotics in it and a PH indicator." If there is an infection, typically the PH of that solution would change and the solu- tion would change color. However, there is no antifungal medication in that solution, Dr. Thompson noted. Going the medical route With this particular patient, the day after the surgery Dr. Thompson received a call from the lab saying that the donor rim was growing fungus. "I immediately called the patient and put him on an anti- fungal medication," he said. By postoperative day 8, the patient was complaining that his eye was becoming light sensitive, and it had become inflamed. Dealing with a DMEK endophthalmitis case W hile the risk of an endophthalmitis infection following a corneal transplant is low, such infections can occur and determining how to best proceed is critical. In the first reported case of its kind, practi- tioners found themselves dealing with a fungal endophthalmitis case following a DMEK transplantation, according to Matthew Thompson, MD, Green Bay, Wisconsin. The case, published in the Open Ophthalmology Journal, initially appeared to proceed uneventfully. 1 "After doing any cornea transplant, most cornea specialists are going to take the leftover piece called the donor rim and send it to the labora- tory to culture," Dr. Thompson said, adding that in about 10% of cases bacteria will grow from that rim, but almost never does the patient end up with an infection from this. However, fungal infections are a different story. While these are rarely found on donor rims, when they do occur, they carry a higher On the fungal fence Keratic precipitates on the donor DMEK graft Source: Matthew Thompson, MD Research highlight

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