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Yuan Y, Liu X, Zhou L, Ding W, Zhang L, Zheng J. Case report: A case of acute postoperative endophthalmitis following penetrating keratoplasty due to carbapenem-resistant Klebsiella Pneumoniae and literature review. Front Med (Lausanne) 2023; 10:1110411. [PMID: 37265480 PMCID: PMC10229784 DOI: 10.3389/fmed.2023.1110411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/04/2023] [Indexed: 06/03/2023] Open
Abstract
A 22-year-old lady underwent penetrating keratoplasty for serious keratoconus. The following day, it was complicated by the development of infectious endophthalmitis. The source of infection was identified as carbapenem-resistant Klebsiella pneumoniae. The donor corneal button might be playing a role in infection transmission due to carbapenem-resistant Klebsiella pneumoniae in a sputum culture when the donor was still alive. Nosocomial infections were typically severe, rapidly progressive, and difficult to treat. Finally, the patient underwent therapeutic penetrating keratoplasty again with complete resolution of the infection.
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Affiliation(s)
- Ying Yuan
- Department of Ophthalmology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou Province, China
- School of Clinical Medical, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Xiaoyuan Liu
- Department of Ophthalmology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou Province, China
- School of Clinical Medical, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Li Zhou
- Department of Ophthalmology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou Province, China
- School of Clinical Medical, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Wuchun Ding
- Department of Ophthalmology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou Province, China
- School of Clinical Medical, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Liying Zhang
- Department of Ophthalmology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou Province, China
- School of Clinical Medical, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Jinhua Zheng
- Department of Ophthalmology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou Province, China
- School of Clinical Medical, Guizhou Medical University, Guiyang, Guizhou Province, China
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Calisir K, Mohamed HM, Yussuf AA. Multi-drug resistant Klebsiella-induced corneal ulcer following pterygium surgery: a case report. BMC Ophthalmol 2023; 23:175. [PMID: 37095479 PMCID: PMC10124041 DOI: 10.1186/s12886-023-02928-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 04/19/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Management of pterygium is dependent on the grading of pterygium and its clinical presentation (inflamed or quiescent), and surgical excision is the final choice of treatment for the pterygium extending beyond the limbus. Infectious keratitis is one of the most commonly reported complications in recent years. To the best of our knowledge, Klebsiella keratitis after pterygium surgery has not been described in the current literature. Here, we report a patient with corneal ulcer formation following pterygium surgical excision. CASE PRESENTATION A 62-year-old woman presented with complaints of pain, blurred vision, photophobia and redness in her left eye for a month. She had a history of pterygium surgical excision two months ago. Slit-lamp examination showed conjunctival congestion, a central whitish corneal ulcer with a central epithelial defect, and hypopyon. Corneal scraped sample revealed multidrug resistant (MDR) Klebsiella pneumonia and the strain was found to be sensitive to cefoxitin and ciprofloxacin. Intracameral cefuroxime (1 mg/0.1 mL) injection, fortified cefuroxime ophthalmic suspension (50 mg/mL) and moxifloxacin ophthalmic suspension (0.5%) were successfully administered to control the infection. Since residual central stromal opacification remained persistent, final visual acuity did not improve beyond finger counting at two meters. CONCLUSIONS Klebsiella keratitis is a rare and sight-threatening complication following pterygium excision. This report emphasizes the importance of close follow-up examination following pterygium surgeries.
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Affiliation(s)
- Kenan Calisir
- Mogadishu Somalia Turkey Training and Research Hospital, Ophthalmology Department, Mogadishu, Somalia.
| | - Hassan Muhumed Mohamed
- Mogadishu Somalia Turkey Training and Research Hospital, Ophthalmology Department, Mogadishu, Somalia
| | - Aisha Abdirahman Yussuf
- Mogadishu Somalia Turkey Training and Research Hospital, Ophthalmology Department, Mogadishu, Somalia
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Dhiman R, Sharma N, Chauhan J. Klebsiella keratitis presenting as a ring infiltrate in an adolescent girl. Taiwan J Ophthalmol 2023; 13:84-87. [DOI: 10.4103/tjo.tjo-d-22-00101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/29/2022] [Indexed: 01/06/2023] Open
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Infectious keratitis caused by Klebsiella spp.: predisposing factors, presentation, and management. Int Ophthalmol 2022; 43:1169-1173. [PMID: 36114910 DOI: 10.1007/s10792-022-02515-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE To study predisposing factors, clinical presentation and management strategies for Klebsiella keratitis. METHODS A retrospective case review was performed on clinical records of culture-proven Klebsiella keratitis cases in a tertiary referral center over an 8-year period (from 2012 to 2020). RESULTS Thirty eight episodes of culture-proven Klebsiella keratitis were identified in 37 patients. The mean age of the patients was 62.9 years (range, 24-101). Multiple predisposing factors were identified in 33 eyes including history of previous keratoplasty (n = 11) history of ocular trauma (n = 7), preexisting ocular surface disease (n = 7) and diabetes (n = 6). Corrected distance visual acuity (CDVA) at presentation was light perception (LP) in 16 patients, hand motion (HM) in 12, counting fingers (CF) at 50 cm in 5, CF at 1 m in 1, CF at 2 m in 2. One patient had a CDVA of 3/10. On initial examination Hypopyon was detected in 21 eyes. Descemet's membrane folds were present in 1 eye. Corneal thinning was identified in 20 eyes and perforation occurred in 4 patients. Corneal ulcer progressed to endophthalmitis in one patient. Microbiologic sensitivity testing showed that 89.5% isolates were sensitive to amikacin (34/38),88.9%sensitive to ceftazidime (32/36),94.4% were sensitive to gentamicin (34/36),97.2% sensitive to ciprofloxacin (35/36), and 100% to levofloxacin (26/26).Ultimately, one or more surgical procedures was needed in 21 patients. CONCLUSION Previous keratoplasty, history of ocular trauma, ocular surface disease and systemic disease such as diabetes are major risk factors for Klebsiella keratitis. In most of the patients, surgical and tectonic procedures were necessary to control the infection.
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Singh RB, Das S, Chodosh J, Sharma N, Zegans ME, Kowalski RP, Jhanji V. Paradox of complex diversity: Challenges in the diagnosis and management of bacterial keratitis. Prog Retin Eye Res 2021; 88:101028. [PMID: 34813978 DOI: 10.1016/j.preteyeres.2021.101028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 12/12/2022]
Abstract
Bacterial keratitis continues to be one of the leading causes of corneal blindness in the developed as well as the developing world, despite swift progress since the dawn of the "anti-biotic era". Although, we are expeditiously developing our understanding about the different causative organisms and associated pathology leading to keratitis, extensive gaps in knowledge continue to dampen the efforts for early and accurate diagnosis, and management in these patients, resulting in poor clinical outcomes. The ability of the causative bacteria to subdue the therapeutic challenge stems from their large genome encoding complex regulatory networks, variety of unique virulence factors, and rapid secretion of tissue damaging proteases and toxins. In this review article, we have provided an overview of the established classical diagnostic techniques and therapeutics for keratitis caused by various bacteria. We have extensively reported our recent in-roads through novel tools for accurate diagnosis of mono- and poly-bacterial corneal infections. Furthermore, we outlined the recent progress by our group and others in understanding the sub-cellular genomic changes that lead to antibiotic resistance in these organisms. Finally, we discussed in detail, the novel therapies and drug delivery systems in development for the efficacious management of bacterial keratitis.
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Affiliation(s)
- Rohan Bir Singh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; Department of Ophthalmology, Leiden University Medical Center, 2333, ZA Leiden, the Netherlands
| | - Sujata Das
- Cornea and Anterior Segment Services, LV Prasad Eye Institute, Bhubaneshwar, India
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Namrata Sharma
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Michael E Zegans
- Department of Ophthalmology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Regis P Kowalski
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; The Charles T Campbell Ophthalmic Microbiology Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vishal Jhanji
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; The Charles T Campbell Ophthalmic Microbiology Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Song A, Deshmukh R, Lin H, Ang M, Mehta JS, Chodosh J, Said DG, Dua HS, Ting DSJ. Post-keratoplasty Infectious Keratitis: Epidemiology, Risk Factors, Management, and Outcomes. Front Med (Lausanne) 2021; 8:707242. [PMID: 34307431 PMCID: PMC8292647 DOI: 10.3389/fmed.2021.707242] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 06/09/2021] [Indexed: 12/26/2022] Open
Abstract
Post-keratoplasty infectious keratitis (PKIK) represents a unique clinical entity that often poses significant diagnostic and therapeutic challenges. It carries a high risk of serious complications such as graft rejection and failure, and less commonly endophthalmitis. Topical corticosteroids are often required to reduce the risk of graft rejection but their use in PKIK may act as a double-edged sword, particularly in fungal infection. The increased uptake in lamellar keratoplasty in the recent years has also led to complications such as graft-host interface infectious keratitis (IIK), which is particularly difficult to manage. The reported incidence of PKIK differs considerably across different countries, with a higher incidence observed in developing countries (9.2-11.9%) than developed countries (0.02-7.9%). Common risk factors for PKIK include the use of topical corticosteroids, suture-related problems, ocular surface diseases and previous corneal infection. PKIK after penetrating keratoplasty or (deep) anterior lamellar keratoplasty is most commonly caused by ocular surface commensals, particularly Gramme-positive bacteria, whereas PKIK after endothelial keratoplasty is usually caused by Candida spp. Empirical broad-spectrum antimicrobial treatment is the mainstay of treatment for both PKIK, though surgical interventions are required in medically refractory cases (during the acute phase) and those affected by visually significant scarring (during the late phase). In this paper, we aim to provide a comprehensive overview on PKIK, encompassing the epidemiology, risk factors, causes, management and outcomes, and to propose a treatment algorithm for systematically managing this challenging condition.
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Affiliation(s)
- Anna Song
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rashmi Deshmukh
- Department of Ophthalmology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Haotian Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Marcus Ang
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Jodhbir S. Mehta
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - James Chodosh
- Harvard Medical School, Massachusetts Eye and Ear, Boston, MA, United States
| | - Dalia G. Said
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Department of Ophthalmology, Queen's Medical Centre, Nottingham, United Kingdom
| | - Harminder S. Dua
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Department of Ophthalmology, Queen's Medical Centre, Nottingham, United Kingdom
| | - Darren S. J. Ting
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Department of Ophthalmology, Queen's Medical Centre, Nottingham, United Kingdom
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Basak S, Basak SK, Saha S. Acute interface infectious keratitis with multidrug resistant Klebsiella and Escherichia Coli following deep anterior lamellar keratoplasty. Indian J Ophthalmol 2021; 68:1678-1680. [PMID: 32709821 PMCID: PMC7640860 DOI: 10.4103/ijo.ijo_2348_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Acute interface infectious keratitis (AIIK) is a rare and devastating complication following lamellar keratoplasty. Here, we report a case of AIIK following deep anterior lamellar keratoplasty (DALK) caused by double gram-negative bacilli and required urgent therapeutic penetrating keratoplasty (TPK). Microbiology revealed co-infection with Klebsiella and E. Coli sensitive only to colistin. Donor rim culture also grew Klebsiella. TPK was successful in controlling the infection and the patient responded to topical fortified amikacin and ciprofloxacin. Since optical quality tissue was used, the patient regained 20/40 vision postoperatively. This report highlights that immediate TPK and intense antimicrobial therapy can salvage these eyes with good visual outcome.
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Affiliation(s)
- Soham Basak
- Department of Cornea, Disha Eye Hospitals, Barrackpore, West Bengal, India
| | - Samar K Basak
- Department of Cornea, Disha Eye Hospitals, Barrackpore, West Bengal, India
| | - Suman Saha
- Department of Microbiology, Priyamvada Birla Aravind Eye Hospital, Kolkata, West Bengal, India
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Das S, Chaurasia S, Sharma S, Das S. Early postoperative infection following lamellar keratoplasty: a review. Br J Ophthalmol 2021; 106:741-754. [PMID: 33941590 DOI: 10.1136/bjophthalmol-2020-318305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 11/04/2022]
Abstract
With the growing popularity of lamellar keratoplasty for selective replacement of diseased corneal tissue, it is important to understand the risk of developing an infection after the procedure. Although lesser than that postpenetrating keratoplasty, the reports on post lamellar keratoplasty infectious keratitis are not negligible. Trends of acute infections arising within 2 months of surgery are a subject of interest. Most of these infections are reported post Descemet's stripping endothelial keratoplasty with a preponderance of Candida species. A donor to host transmission of infection is not uncommon. Among the Candida cases, about 80% seem to occur due to a donor to host transmission. Infections presenting as or progressing to endophthalmitis lead to a poor visual outcome. Strict aseptic measures and protocols during corneal tissue harvesting, tissue processing, tissue storage and surgery are essential to prevent occurrence of these infections. After the infection has occurred, determining the aetiology and drug susceptibility through microbiological testing is vital. This helps to guide treatment protocols and hence determines final outcome of these cases. Most cases require some form of surgical management for resolution of infection, most often a graft removal and therapeutic keratoplasty. Secondary surgical interventions are performed to restore graft clarity and achieve a good final visual outcome.
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Affiliation(s)
- Shilpa Das
- Cornea Service, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Sunita Chaurasia
- Cornea & Anterior Segment Service, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Savitri Sharma
- Jhaveri Microbiology Centre, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Sujata Das
- Cornea & Anterior Segment Service, LV Prasad Eye Institute, Bhubaneswar, Odisha, India
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Sharma N, Kaur M, Titiyal JS, Aldave A. Infectious keratitis after lamellar keratoplasty. Surv Ophthalmol 2020; 66:623-643. [PMID: 33217327 DOI: 10.1016/j.survophthal.2020.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 11/02/2020] [Accepted: 11/07/2020] [Indexed: 11/30/2022]
Abstract
Infectious keratitis after lamellar keratoplasty is a potentially devastating complication that may severely limit the visual and anatomical outcomes. The deep-seated location of the infiltrates, sequestration of the pathogenic microorganisms and limited penetration of the currently available antimicrobial agents often results in delayed diagnosis that may jeopardize the management in these cases. Fungal keratitis is more common as compared with bacterial or viral keratitis and classically presents as white interface infiltrates that may not be associated with significant inflammation. Confocal microscopy may help to establish a rapid diagnosis in such cases, and anterior segment optical coherence tomography may be used to determine the extent of infection and monitor its progression. Conservative measures such as topical antimicrobials and interface irrigation with antimicrobial agents may be done. Surgical intervention in the form of partial excision/removal of the graft in endothelial keratoplasty or a full-thickness keratoplasty is often required for the effective management of deep-seated infections. Timely diagnosis and intervention may result in complete resolution of infection in both anterior lamellar and endothelial keratoplasty. Infections after anterior lamellar keratoplasty have a fair prognosis, and a clear graft with functional visual acuity may be achieved in most cases. By contrast, infections after endothelial keratoplasty have a guarded prognosis, and the presence of concomitant endophthalmitis may further complicate the graft survival and visual outcomes.
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Affiliation(s)
- Namrata Sharma
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
| | - Manpreet Kaur
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jeewan S Titiyal
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Anthony Aldave
- The Jules Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, USA
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Infectious interface keratitis (IIK) following lamellar keratoplasty: A literature review. Ocul Surf 2019; 17:635-643. [DOI: 10.1016/j.jtos.2019.08.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/22/2019] [Accepted: 08/05/2019] [Indexed: 11/22/2022]
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D’Oria F, Galeone A, Pastore V, Cardascia N, Alessio G. Multi-drug resistant Enterococcus faecium in late-onset keratitis after deep anterior lamellar keratoplasty: A case report and review of the literature. Medicine (Baltimore) 2019; 98:e17140. [PMID: 31517855 PMCID: PMC6750735 DOI: 10.1097/md.0000000000017140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Interface keratitis after lamellar keratoplasty is one of the causes of graft failure. We report the first case of microbiologically proven Enterococcus faecium infection following deep anterior lamellar keratoplasty (DALK) and review the available literature. PATIENT CONCERNS A 37-years-old Caucasian man presented with pain, redness and severe vision loss in his right eye. Five weeks before, he underwent DALK using the FEMTO LDV Z8 in the same eye for the surgical correction of keratoconus. DIAGNOSES Upon presentation, slit-lamp biomiscroscopy revealed corneal graft edema with multiple infiltrates located in the graft-host interface. INTERVENTIONS Therapeutic penetrating keratoplasty (PKP) was carried out in addition with cultures of the donor lenticule removal. Laboratory results isolated a multi-resistant Enterococcus faecium interface infection. According to the antibiogram, the patient was treated with systemic Tigecycline and Linezolid for 7 days. OUTCOMES During the following weeks, clinical features improved over time and no signs of active infection were visible seven months postoperatively. LESSONS Early PKP showed to be a good therapeutic option with great anatomic and functional outcomes.
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