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 Table of Contents  
Year : 2018  |  Volume : 111  |  Issue : 1  |  Page : 15-19

Ocular infections after penetrating keratoplasty

Ophthalmology Department, JSS Medical College and Hospital, Mysore, India

Date of Web Publication26-Jul-2018

Correspondence Address:
S.K. Prabhakar
Ophthalmology Department, JSS Medical College and Hospital, Mysore 570004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejos.ejos_27_17

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Context Early diagnosis of ocular infections following penetrating keratoplasty (PK) depending on clinical presentation in addition to ancillary laboratory investigations facilitates preservation of useful vision and prevention of further intraocular spread.
Aim The aim of this research was to study donor and recipient risk factors in post-PK ocular infections.
Patients and methods This is an interventional prospective study. This prospective study was conducted in 34 patients who underwent PK under peribulbar anaesthesia from 2014 to 2016 in a tertiary hospital. Six patients developed signs and symptoms suspicious of postoperative infections. Inclusion and exclusion criteria are mentioned. MS excel was used for statistical analyses.
Results The mean age was 53±18.04 years, ranging from 12 to 86 years with 24 (70.59%) male and 10 (29.41) female individuals studied. There were 24 (70.59%) right eyes and 10 left eyes (29.41). The mean age was 63.97±16.8 years among the donors. Six (17.64%) patients developed postoperative infections that included one patient with Pseudomonas aeroginosa keratoconjunctivitis, two patients with fusarium fungal keratitis and growth could not be established in the remaining three cases. Positive microbial identification by culture was possible in three (8.82%) patients.
Conclusion Microbial identification was confirmed in three cases, and three cases were negative for growth. The risk factor found among recipients were vegetative injury, dust fall and eye rubbing, as well as taking a very hot bath. Graft clarity restoration significantly improved after topical management with fortified antibiotics and antifungal agents.

Keywords: bacterial keratitis, endophthalmitis, fungal keratitis, penetrating keratoplasty, suture track abscess

How to cite this article:
Prabhakar S, Arra RR. Ocular infections after penetrating keratoplasty. J Egypt Ophthalmol Soc 2018;111:15-9

How to cite this URL:
Prabhakar S, Arra RR. Ocular infections after penetrating keratoplasty. J Egypt Ophthalmol Soc [serial online] 2018 [cited 2019 Mar 26];111:15-9. Available from: http://www.jeos.eg.net/text.asp?2018/111/1/15/237607

  Introduction Top

Early diagnosis and management of postpenetrating keratoplasty (PK) ocular infections significantly reduces visual morbidity, thus enhancing graft survival rates. According to national transplant registry data, endophthalmitis incidence reported in 11 320 transplanted eyes in UK was 0.67 and 0.16%, which occurred within 6 weeks after surgery [1].

Although suture-related problems, persistent epithelial defects and failed grafts form predisposing factors, infectious keratitis was leading the cause of corneal graft failure [2],[3],[4],[5]. Prolonged topical corticosteroid administration was a major risk factor for post-PK infectious keratitis, and indolent organisms such as  Moraxella More Details were prevalent in failed grafts [6].

The present study attempts to find out risk factors for post-PK infections and treatment modalities offered to combat the disastrous effects of infections to preserve useful vision and to prevent further intraocular infection dissemination.

  Patients and methods Top

Thirty-four patients underwent PK between 2014 and 2016 under peribulbar anaesthesia and one case under general anaesthesia. Donor graft was anchored with continuous and intermittent sutures by 10 0 Ethilon (Johnson & Johnson Private limited, Aurangabad, Maharashtra, India) and soft bandage contact lens was placed at the end of surgery. Postoperative keratitis was suspected in six patients depending on physical signs and symptoms.

Case 1

This patient underwent PK for his childhood leucoma in his left eye. One year after PK, the patient presented with a history of stick injury that incited fungal keratitis, which was treated effectively with topical natamycin eye drops and cycloplegics.

Case 2

This patient had repeat PK for his pseudophakic bullous keratopathy (graft being clear for 12 years) in his RE (AC Lens, Appasamy Ocular Devices Private limited, Vadamangalam, Pondicherry, Tamilnadu, India), and after 3 months the patient presented with fungal keratitis following a hot bath and vigorous eye rubbing that were treated effectively with topical natamycin drops.

Case 3

This patient underwent PK for his granular corneal dystrophy and presented after 3 months with irritative signs and symptoms. On examination, suture invasion probably with fungal elements was observed. Removal of contact lens with topical natamycin instillation facilitated improvement.

Case 4

This patient presented 3 months after PK with suture infiltrations and decreased vision; however, no history of injury was obtained. No organisms were identified by KOH, Gram stain and culture. Topical natamycin instillation decreased the infiltrations and the patient showed improvement in vision.

Case 5

The patient had childhood adherent leucoma with extensive posterior synechie and underwent PK. After 5 months, the patient developed pseudomembranous keratoconjunctivitis and pseudomonas aeroginosa was isolated. Risk factor was dust fall and eye rubbing, which were treated effectively with fortified cefoxime eye drops 50 mg/ml.

Case 6

This patient underwent PK for infected perforated corneal ulcer (microbial investigations not known) and organisms could not be isolated. Unfortunately after 2 months the patient developed endophthalmitis and evisceration was done.

  Results Top

A total of 34 patients underwent PK under peribulbar anaesthesia with a mean age of 53±18.04 years, with 24 (70.59%) male and 10 (29.41%) female patients. There were 24 right eyes (70.59%) and 10 (29.41%) left eyes. The mean age of the donors was 63.97±16.8 years. Six (17.64%) patients developed postoperative infections that included one Pseudomonas aeroginosa keratoconjunctivitis, two cases of fusarium fungal keratitis and growth could not be established in three cases ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6]). Microbial identification was confirmed in three (8.82%) patients. The occupation, indications for PK procedure, additional procedures performed and microbial identification of the patients in the study are shown in Graphs 1-4

. [Table 1] shows clinical characterizations of infectious process.
Figure 1 Picture showing infiltrates tracking along suture lines and graft host junction.

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Figure 2 Fungal infiltrate clumping, with suture involvement in the regrafted eye.

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Figure 3 Classical distribution of infiltrates seen at the needle entry bites and suture tracks.

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Figure 4 Blepharokerato-conjuctivitis in the grafted eye with suture track infiltrations and severe meibomianitis.

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Figure 5 Thick and tenacious pseudomembrane formation over upper palpebral conjunctiva.

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Figure 6 Postpenetrating graft showing intermittent sutural infiltration.

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Table 1 Showing clinical characterization of present study patients

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  Discussion Top

Accidental stick injury and exposure to vegetative material is a known risk factor for fungal keratitis development. Unlike classical description of fungal corneal ulcers, post-PK fungal infection involvement was limited to suture tracks and infiltrations developed along or amidst host graft junction and especially at the needle entry, plausibly signifying affinity of fungal elements to propagate along the suture tracks. A previous study showed a 7.4% incidence of microbial keratitis, and it commonly seems to start from the donor–recipient border in most cases similar to the clinical picture of this present study [7].

Eye rubbing following dust fall is a known predisposing factor for corneal ulcer development. Pathogeneses might be explained in pseudomonas-infected patients who presented with characteristic and classical pseudomembrane formation over superior palpebral conjunctiva, with infiltrations along the suture tracts decreasing the graft clarity. The condition improved after removing the membrane and soft bandage contact lens with institution of active intensive topical therapy by fortified cefoxime eye drops (50 mg/ml).

Pre-existing recurrence of infection with doubtful light perception after PK was a risk factor and intraocular spread was noted after 3 months, causing endophthalmities and therefore evisceration was ultimately resorted. Chen and colleagues observed endophthalmitis as a serious issue with regard to reduced graft survival and poor visual outcomes. In delayed endophthalmitis cases, sequestration of microbes within corneal tissue was suspected.

Pathogenesis of post-PK fungal keratitis that occurred after taking a hot bath is difficult to explain. Probably soup and other materials could have predisposed for fungal keratitis that had a fungal infiltrate clump formed at the suture junction.

It is unlikely that pre-existing ocular infections in donors could have been triggering factors for systemic infections ruled out by nonreactivity of HIV and HbsAg serological tests. It may be prudent to take conjunctival sac swabs at the time of enucleation for KOH, Grams stain, culture and sensitivity to identify organisms.

Vajpayee et al. [8] reported infectious keratitis as the leading cause for corneal graft failures that occurred commonly within 1 year of surgery and reported that pneumococcal species and Staphylococcus aureus are most prevalent in the developed world, whereas Staphylococcus epidermidis was the most common organism in the developing world. The same study reported S. epidermidis as the most common organism for infectious keratitis found in India [8].

Another study reported exposed, loose or broken sutures, persistent epithelial defects or severe punctuate keratopathy, soft contact lens insertion including therapeutic lenses, graft hypoesthesia, keratoconjunctivitis sicca, previous herpetic eye disease, graft failure, ocular adnexa and lid abnormalities and ongoing external and corneal infections as the most identifiable risk factors. Recurrence of pre-existing conditions such as acanthamoeba and herpes simplex was previously reported [9].

Wagoner [10],[11] reported 4.9% of culture positive post-PK bacterial infectious keratitis compared with 2.9% in the present study. In paediatric post-PK cases, Staphylococcus pneumonia (17.3%) was the most common organism found [10],[11]. Sung et al. [12] revealed 17 (60.71%) patients with bacterial keratitis and 11 (39.29%) with fungal keratitis out of 28 patients. Tixier reported bullous keratopathy (50%) as the common indication for PK second to pre-existing microbial keratitis in 25% [13]. Present study revealed 29.41% for bullous keratopathy, 20.58% constituted for graft failures, and 14.70% for microbial keratitis causing perforations as the common risk factor.

  Conclusion Top

Recipient risk factors identified were vegetative injury, eye rubbing after dust fall and taking a hot bath. Soft bandage contact lens might be a predisposing factor; nevertheless, no organismal growth was reported after 48 h of culture of contact lens. Host tissue response to graft integration cannot be totally ruled out with negative results after microbial culture.

Soft bandage contact lens and sutures were identified as the risk factors and possible predisposing factors; however, inclusion of donor’s conjunctival swabs during enucleation may throw some light on microbial identification. Preventive measures, microbiologic diagnostic procedures and antibiotic/antifungal therapy are the mainstay of treatment along with infected suture removal and soft bandage contact lens. Therapeutic keratoplasty might be considered for unresolving post-PK infectious keratitis when conservative treatment fails.


The authors thank the head of institution, Ophthalmology Department, OT staff and patients for their unending cooperation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Chen JY, Jones MN, Srinivasan S, Neal TJ, Armitage WJ, Kaye SB; NHSBT Ocular Tissue Advisory Group and Contributing Ophthalmologists (OTAG Audit Study 18). Endophthalmitis after penetrating keratoplasty. Ophthalmology 2015; 122: 25–30.  Back to cited text no. 1
Vajpayee RB, Sharma N, Sinha R, Agarwal T, Singhvi A. Infectious keratitis following keratoplasty. Surv Ophthalmol 2007; 52:1–12.  Back to cited text no. 2
Hood CT, Lee BJ, Jeng BH. Incidence, occurrence rate, and characteristics of suture-related corneal infections after penetrating keratoplasty. Cornea 2011;30:624–628.  Back to cited text no. 3
Das S, Constantinou M, Ong T, Taylor HR. Microbial keratitis following corneal transplantation. Clin Exp Ophthalmol 2007; 35:427–431.  Back to cited text no. 4
Sonavane A, Sharma S, Gangopadhyay N, Bansal AK. Clinico-microbiological correlation of suture-related graft infection following penetrating keratoplasty. Am J Ophthalmol 2003; 135:89–91.  Back to cited text no. 5
Constantinou M, Jhanji V, Vajpayee RB. Clinical and microbiological profile of post-penetrating keratoplasty infectious keratitis in failed and clear grafts. Am J Ophthalmol 2013; 155:233–237.  Back to cited text no. 6
Akova YA, Onat M, Koc F, Nurozler A, Duman S. Microbial keratitis following penetrating keratoplasty. Ophthalmic Surg Lasers 1999; 30:449–455.  Back to cited text no. 7
Vajpayee RB, Boral SK, Dada T, Murthy GV, Pandey RM, Satpathy G. Risk factors for graft infection in India: a case-control study. Br J Ophthalmol 2002; 86:261–265.  Back to cited text no. 8
Varley GA, Meisler DM. Complications of penetrating keratoplasty: graft infections. Refract Corneal Surg 1991; 7:62–66.  Back to cited text no. 9
Wagoner MD, Al-Ghamdi AH, Al-Rajhi AA. Bacterial keratitis after primary pediatric penetrating keratoplasty. Am J Ophthalmol 2007; 143:1045–1047.  Back to cited text no. 10
Wagoner MD, Al-Swailem SA, Sutphin JE, Zimmerman MB. Bacterial keratitis after penetrating keratoplasty: incidence, microbiological profile, graft survival, and visual outcome. Ophthalmology 2007; 114:1073–1079.  Back to cited text no. 11
Sung MS, Choi W, You IC, Yoon KC. Factors affecting treatment outcome of graft infection following penetrating keratoplasty. Korean J Ophthalmol 2015; 29:301–308.  Back to cited text no. 12
Tixier J, Bourcier T, Borderie V, Laroche L. Infectious keratitis after penetrating keratoplasty. J Fr Ophtalmol 2001; 24:597–602.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1]


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