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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 886-888

Post-Descemet's membrane endothelial keratoplasty Pseudomonas graft infection

Cornea and Anterior Segment Services, L. J. Eye Institute, Ambala, Haryana, India

Date of Submission10-May-2022
Date of Acceptance15-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Vikas Mittal
Cornea and Anterior Segment Services, L. J. Eye Institute, 251, Model Town, Ambala City - 134 002, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1182_22

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To report evaluation and management of graft-host interface keratitis post-Descemet's membrane endothelial keratoplasty (DMEK). A 70-year-old lady with pseudophakic bullous keratopathy who underwent DMEK and developed interface interstitial keratitis on the first postoperative day. Cultures of corneal button revealed gram-negative bacilli (Pseudomonas aeruginosa). Prompt surgical intervention in the form of removal of donor Descemet's membrane and targeted antibacterial therapy helped in the complete resolution of infection. Descemet's stripping endothelial keratoplasty (DSEK) was performed postresolution of infection which yielded a good visual outcome for the patient. Donor rim culture helps immensely in identifying organisms in cases presenting in the early postoperative period.

Keywords: Case report, corneoscleral rim culture, Descemet's membrane endothelial keratoplasty, infectious interface keratitis, Pseudomonas aeruginosa

How to cite this article:
Shah V, Kaur I, Jain N, Mittal V. Post-Descemet's membrane endothelial keratoplasty Pseudomonas graft infection. Indian J Ophthalmol Case Rep 2022;2:886-8

How to cite this URL:
Shah V, Kaur I, Jain N, Mittal V. Post-Descemet's membrane endothelial keratoplasty Pseudomonas graft infection. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 30];2:886-8. Available from: https://www.ijoreports.in/text.asp?2022/2/4/886/358146

Interface interstitial keratitis is a new emerging infection of the cornea that may develop after any kind of lamellar keratoplasty.[1],[2] Infection starts at the sequestrated space between host and graft making it difficult to identify the causative organism. Donor rim culture proves to be of immense help, especially in identifying the organism in cases presenting in the early postoperative period.[3] The corneoscleral rim growth and infection in patients correlate well in lamellar keratoplasty compared with penetrating keratoplasty (PK).[4] In the present manuscript, we report the presentation and management outcomes of donor-related post-Descemet's membrane endothelial keratoplasty (DMEK) graft infection.

  Case Report Top

A 70-year-old lady presented to us with a gradual painless blurring of vision in both eyes, which was more severe in the left eye. The patient had undergone cataract surgery in the left eye 3 months earlier at another hospital, following which she did not notice any improvement in vision. Her best-corrected visual acuity (BCVA) was 20/60p and 20/800 in right and left eye, respectively. Intraocular pressures (IOP) in both eyes were normal. On slit-lamp biomicroscopy, central guttae were seen in the right eye and diffuse corneal edema and bullae were noted in the left eye. The rest of the anterior segment examination was normal. The specular count in the right eye was 1185/mm2; pleomorphism and polymegathism were present. Posterior segment examination in the right eye was normal. In the left eye, B-scan showed anechoic vitreous cavity. She was diagnosed with both eye Fuchs endothelial dystrophy and left eye pseudophakic bullous keratopathy for which she underwent Descemet's Membrane Endothelial Keratoplasty (DMEK) in the left eye.

The donor tissue was procured from a distinct eye bank and was transported in cornisol. The DMEK graft was prepared by the surgeon in the operating room. The intraoperative course of surgery was uneventful.

On the first postoperative day, visual acuity in the left eye was 20/100 and IOP was 15 mmHg. On slit-lamp examination, an attached graft with multiple, tiny interface infiltrates in the central cornea with 1 mm hypopyon in anterior chamber (AC) was seen [Figure 1]a B-Scan showed no vitreous echoes.
Figure 1: (a) Slit-lamp photograph of the left eye on the first postoperative day showing tiny infiltrates are seen in the interface. (b) After the removal of the donor Descemet's membrane, peripheral ring-shaped posterior stromal infiltrates are seen. (c) One week after commencement of targeted therapy for Pseudomonas showing a reduction in density of posterior stromal infiltrates. (d) Three weeks after starting targeted therapy showing complete resolution of infiltrates. (e) Clinical picture at 2-year follow-up showing compact cornea with no recurrence of infection. DSEK lenticule is well apposed

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In our practice, we routinely send the corneoscleral rim of all lamellar keratoplasty for microbiological evaluation on blood agar. It was noticed that the rim of the donor used for this patient had a growth of gram-negative bacilli. Considering the virulence of the organism, we planned to remove donor Descemet's membrane (DM) the same day. The donor DM was removed and sent for microbiological evaluation. Intracameral injection of preservative-free moxifloxacin 0.5% and imipenem 0.5% was injected as donor corneoscleral rim had growth of gram-negative bacilli. Considering the virulence of the organism and the tendency for drug resistance, we decided to give the best possible option to our patient and started her on a topical antibiotic (gatifloxacin 0.5% and fortified imipenem 0.5%, one hourly each) along with oral ciprofloxacin 500 mg twice a day. On the third postoperative day, slit-lamp examination showed corneal edema, central epithelial defect, and posterior stromal ring-shaped infiltrate [Figure 1]b. Based on our previous experience of treating multidrug-resistant Pseudomonas infections, previously reported outcomes[5] and antibiotic susceptibility report topical antibiotics were changed accordingly (fortified amikacin 2.5%, ciprofloxacin 0.3%, and imipenem 1%). Oral ciprofloxacin 500 mg was continued twice a day. The organism identified on cultures of the corneoscleral rim and explanted DM was the same (Pseudomonas aeruginosa).

After the next 2 days of initiation of targeted therapy, a reduction in infiltrate was noted, hence topical antibiotic frequency was reduced to 2 h. Over the next 1 week, there was a significant clinical improvement [Figure 1]c and topical corticosteroid (loteprednol etabonate 0.5%, 4 times/day) was added to reduce inflammation. After 3 weeks, a complete resolution of infection was noted [Figure 1]d and after 2 months, the inflammation had settled completely. At this point, Descemet's stripping endothelial keratoplasty (DSEK) using manually dissected graft tissue was performed using the standard technique. One month post-DSEK, slit-lamp examination showed a well-attached lenticule, compact cornea, normal IOP, and BCVA of 20/50p in the operated eye [Figure 1]e. Fundus examination revealed a normal disc. At 24-months follow-up, BCVA was 20/40. No recurrence of infection was noticed during the follow-up period.

  Discussion Top

To our knowledge (PubMed), 24 post-DMEK interface infections have been reported so far [Table 1]. Out of these, 16 were fungal, six were bacterial (5 gram-positive cocci, 1 gram-negative bacilli) and in two cases conservative management was done and the organism was not evaluated. Of the 24 cases, seven were identified to be donor-related (6 fungal, 1 bacterial) where the donor corneoscleral rim was found to be positive of the respective organism. Only one case of proven bacterial interface interstitial keratitis that was donor-related has been reported in the literature which was nontubercular mycobacterium (Mycobacterium chelonae). The only reported post-DMEK gram-negative infection (Pseudomonas aeruginosa) was thought to be due to the use of a bandage contact lens and nonsteroidal anti-inflammatory drug (NSAID) induced epitheliopathy. The donor rim was not cultured in this case as reported by the authors.[6]
Table 1: Table showing previous studies reporting post-DMEK infection, their management, and outcomes

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In our patient, we suspect the infection to be donor-related as gram-negative bacilli (Pseudomonas) was isolated on corneoscleral rim as well as in explanted DM. We discussed with the eye bank and a thorough search for the possible cause of septicemia in the donor, e.g., longer hospital stay, presence of diabetes, etc., was made, but none was found to be present.[17],[18] Death to preservation time in our case was 4.11 h while the cause of death was a road traffic accident. The eye bank follows all guidelines and standards of protocols for corneal tissue harvesting and distribution. We checked for the mate cornea of the same donor that was sent to another surgeon who used it for DSEK in a PBK patient. The patient developed post-DSEK interface infection but was managed conservatively. After the resolution of the infection, the patient had secondary glaucoma and the final visual acuity was the perception of light (personal communication with the surgeon).

  Conclusion Top

To our knowledge, this is the first report of Pseudomonas aeruginosa causing interface infectious keratitis, which was donor-related. The protocol of sending corneoscleral rim in lamellar keratoplasty helped us immensely in planning our management. Also delaying the second intervention for visual rehabilitation and doing it in a quiet eye helped in better graft survival and preventing recurrence.[19],[20]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sharma N, Kaur M, Titiyal JS, Aldave A. Infectious keratitis following lamellar keratoplasty. Surv Ophthalmol 2021;66:623-43.  Back to cited text no. 1
Srirampur A, Mansoori T, Reddy AK, Katta KR, Chandrika TN. Management of Nocardia interface keratitis after Descemet membrane endothelial keratoplasty. Cornea 2019;38:1599-601.  Back to cited text no. 2
Fontana L, Moramarco A, Mandarà E, Russello G, Iovieno A. Interface infectious keratitis after anterior and posterior lamellar keratoplasty. Clinical features and treatment strategies. A review. Br J Ophthalmol 2019;103:307-14.  Back to cited text no. 3
Busin M, Giannaccare G, Myerscough J, Bovone C, Scorcia V, Campos EC. Donor-to-host transmission of infection: Contrasting outcomes of lamellar and penetrating keratoplasty. Transpl Int 2020;33:462-4.  Back to cited text no. 4
Jain R, Murthy SI, Motukupally SR. Clinical outcomes of corneal graft infections caused by multi–drug resistant pseudomonas aeruginosa. Cornea 2014;33:22-6.  Back to cited text no. 5
Gunaydin NT, Tanyıldız B, Kandemir B, Simsek S. Infectious interface keratitis after Descemet membrane endothelial keratoplasty. Arq Bras Oftalmol 2021. doi: 10.5935/0004-2749.20220059.  Back to cited text no. 6
Vaidya NS, Epstein RH, Majmudar PA. Fungal infectious interface keratitis presenting 2 years after descemet membrane endothelial keratoplasty. Cornea 2022;41:917-20.  Back to cited text no. 7
Augustin VA, Weller JM, Kruse FE, Tourtas T. Fungal interface keratitis after Descemet membrane endothelial keratoplasty. Cornea 2018;37:1366-9.  Back to cited text no. 8
Thompson M, Carli D. First reported case of donor related candida endophthalmitis after descemet membrane endothelial keratoplasty. Open Ophthalmol J 2017;11:117-21.  Back to cited text no. 9
Doshi H, Pabon S, Price MO, Feng MT, Price Jr FW. Overview of systemic Candida infections in hospital settings and report of Candida after DMEK successfully treated with antifungals and partial graft excision. Cornea 2018;37:1071-4.  Back to cited text no. 10
Beckman KA, Milner MS, Majmudar PA, Luchs JI. Late-onset fungal interface keratitis following endothelial keratoplasty with positive donor fungal culture. Am J Ophthalmol Case Rep 2020;18:100707. doi: 10.1016/j.ajoc.2020.100707.  Back to cited text no. 11
Sánchez-Ventosa Á, Cano-Ortiz A, Cuadrado AV. Early penetrating keratoplasty after interface fungal keratitis in Descemet membrane endothelial keratoplasty. Arch Soc Esp Oftalmol 2021;96:106-9.  Back to cited text no. 12
Van Landeghem R, Foets B, Desmet S, Vanhaecke M, Hua M-T. Donor-related nontuberculous mycobacterial interface infection after Descemet membrane endothelial keratoplasty. Cornea 2019;38:632-4.  Back to cited text no. 13
Janeschitz-Kriegl L, Dimacali V, Sagri D, Scholl HP, Gatzioufas Z, Balidis M. Post-DMEK bacterial interface keratitis treated with intrastromal and intracameral antibioticorneoscleral. Klin Monatsbl Augenheilkd 2020;237:403-5.  Back to cited text no. 14
Sudana P, Chaurasia S, Joseph J, Mishra DK. Delayed postoperative interface keratitis due to Enterococcus faecalis after Descemet membrane endothelial keratoplasty. BMJ Case Rep 2021;14:e238389. doi: 10.1136/bcr-2020-238389.  Back to cited text no. 15
Tu EY, Majmudar PA. Adjuvant stromal amphotericin B injection for late-onset DMEK infection. Cornea 2017;36:1556-8.  Back to cited text no. 16
Edelstein SL, DeMatteo J, Stoeger CG, Macorneoscleralai MS, Wang C-H. Report of the Eye Bank Association of America medical review subcommittee on adverse reactions reported from 2007 to 2014. Cornea 2016;35:917-26.  Back to cited text no. 17
Gao Y, Li C, Bu P, Zhang L, Bouchard CORNEOSCLERAL. Infectious interface keratitis (IIK) following lamellar keratoplasty: A literature review. Ocul Surf 2019;17:635-43.  Back to cited text no. 18
Das S, Chaurasia S, Sharma S, Das S. Early postoperative infection following lamellar keratoplasty: A review. Br J Ophthalmol 2022;106:741-54.  Back to cited text no. 19
Nahum Y, Russo C, Madi S, Busin M. Interface infection after descemet stripping automated endothelial keratoplasty: Outcomes of therapeutic keratoplasty. Cornea 2014;33:893-8.  Back to cited text no. 20


  [Figure 1]

  [Table 1]


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