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BRIEF COMMUNICATION
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 43-45

Fungal seeding of bandage contact lens with no underlying corneal invasion of boston keratoprosthesis


Department of Cornea and Refractive, Sankara Eye Hospital, Coimbatore, Tamil Nadu, India

Date of Submission27-Jul-2020
Date of Decision16-Oct-2021
Date of Acceptance11-Nov-2021
Date of Web Publication3-Feb-2022

Correspondence Address:
K S Siddharthan
Sankara Eye Hospital, Coimbatore - 641 035, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_125_20

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  Abstract 


Infectious keratitis develops in 13.6% of eyes after keratoprosthesis (Kpro) implantation, with a similar rate of culture-positive bacterial and fungal keratitis. We report a case of 73-year old man who underwent Boston Kpro implantation in the left eye 2 years back. He presented with conjunctival discharge and a whitish growth over the bandage contact lens (BCL) for the past 2 weeks. Slit-lamp examination showed a whitish elevated growth with surrounding diffuse brownish feathery seeding all over the BCL. The BCL which was sent for culture grew fungus. The underlying Kpro was clear with no evidence of any active infiltrate. The patient was started on topical antifungal eye drops and was followed up for 12 months with no recurrence of infection. Educating the patient to be sensitive and to report immediately if they note any abnormality is as important as cleaning or replacing the BCL on a regular basis.

Keywords: Bandage contact lens, fungal infection, keratoprosthesis


How to cite this article:
Siddharthan K S, Agrawal A, Reddy JK. Fungal seeding of bandage contact lens with no underlying corneal invasion of boston keratoprosthesis. J Clin Ophthalmol Res 2022;10:43-5

How to cite this URL:
Siddharthan K S, Agrawal A, Reddy JK. Fungal seeding of bandage contact lens with no underlying corneal invasion of boston keratoprosthesis. J Clin Ophthalmol Res [serial online] 2022 [cited 2022 May 29];10:43-5. Available from: https://www.jcor.in/text.asp?2022/10/1/43/337188



Prosthetic corneas form as the last resort for corneal blindness, especially in eyes with end-stage ocular surface disorders and in those at a high risk for conventional penetrating keratoplasty.[1],[2] The choice of keratoprosthesis (Kpro) depends on the underlying etiology, the anatomy of the ocular surface, and the tear film status.

The most common complications associated with Kpro include retroprosthetic membrane formation, melt, increased intraocular pressure, glaucoma progression, and endophthalmitis.[3]

Here, we report a fungal growth spreading over a bandage contact lens (BCL) without affecting the underlying cornea in the Boston Kpro done 2 years ago. This report underlines the importance to educate all Kpro patients to maintain their BCL with utmost care and the need to be sensitive and to report to the surgeon immediately at the earliest onset of symptoms which can be sight saving as in our case.


  Case Report Top


Seventy-three-year-old man underwent Boston Kpro implantation for multiple failed grafts in the left eye 2 years back. The surgery was uneventful with good graft host junction apposition. His postoperative best-corrected visual acuity (BCVA) was 6/18. BCL (Silver Line, Therapeutic Plus soft BCL 16 mm, plano power, back aspheric with Tri-curve front, beveled peripheral curve with thin and rounded edges) was applied over the Kpro after the surgery. The other eye was normal with a BCVA of 6/6. Postoperatively, he was started on topical Moxifloxacin 0.5% 4 times/day (Vigadex: Alcon) and dexamethasone–chloramphenicol 0.1% 4 times/day (Dexoren-S; Warren) for a period of 3 weeks with gradual tapering to 3/2/1 time at 45 days intervals. Homatropine 2.0% eye drops (Homide; Warren) 2 times/day was given for 2 weeks. Lubricating eye drops (Refresh tears; Allergan) was given 3–4 times regularly. Postoperative period was uneventful and the BCL was replaced regularly at 3–4 months intervals. He was continued on moxifloxacin eye drops and loteprednol etabonate 0.5% (L-pred; Allergan) once a day.[4] Two year post surgery, he presented to us with a complaint of discharge in his left eye and a BCVA of 6/36. His BCL was replaced 2 months prior to this visit. Slit-lamp examination of the left eye showed a whitish elevated growth over the BCL with surrounding diffuse brownish feathery seeding all over the BCL [Figure 1], clinically suggestive of a fungal infection. The BCL was removed and put in Sabaroud's dextrose agar culture media. The underlying Kpro was clear with no evidence of any active infiltrate [Figure 2]. We started the patient on topical amphotericin B 0.15% eye drops, voriconazole 1% eye drops itraconazole eye ointment, moxifloxacin 0.5% eye drops, and 1% carboxy methylcellulose eye drops with a frequency of 3–4 times a day. On the 2nd day of incubation, the culture showed a velvety smoky green mycelial growth surrounding the contact lens [Figure 3]a. Lactophenol cotton blue mount showed septate hyphae and swollen vesicle giving rise to phialides from which chains of conidia arise suggestive of Aspergillus species [Figure 4]. On day 7, the mycelial growth spread with typical conidiophores diffusely covering the whole  Petri dish More Details suggestive of Aspergillus fumigatus [Figure 3]b. The patient was followed regularly and the dose of medications was gradually tapered within 3 weeks and henceforth no infiltrate was noted and the graft remained clear at 12-month follow-up [Figure 5].
Figure 1: Clinically fungal growth seen over the bandage contact lens

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Figure 2: No evidence of infection of underlying keratoprosthesis

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Figure 3: Growth on Sabaroud's dextrose agar media. (a) Day 2. (b) Day 7

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Figure 4: Lactophenol cotton blue mount – Showing Conidiophores suggestive of Aspergillus. Image Courtesy: Dr. Manikandan

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Figure 5: 12-month follow-up with no recurrence

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  Discussion Top


Long-term BCLs are a standard of care for Kpro eyes. Contact lenses protect the cornea from dellen formation adjacent to the front plate of the device, chronic epithelial defects, desiccation, and melt.[2] A recent study demonstrated that the absence of a contact lens after Boston Kpro surgery results in an increased risk of postoperative complications such as corneal melts and infections.[5] However, the lenses may also act as a medium for microorganisms to adhere to and transfer to the ocular surface and may exhibit colonization before the onset of ocular infection.[6]

Infectious keratitis develops in 13.6% of eyes after Kpro implantation, with a similar rate of culture-positive bacterial and fungal keratitis.[7] Venugopal et al.[8] reported infectious keratitis in 26.7% of cases following Auro Kpro. Sharma et al.[9] reported 10% of cases with infections after Kpro and recalcitrant fungal infections were responsible for the explanation of Kpro in their series. Absence of BCL, indefinite steroid prophylaxis, and drug resistance were found to be important risk factors in the development of infectious keratitis after Kpro. The spectrum of responsible fungi in contact lens-related keratitis includes both hyphal molds and yeasts. Filamentous fungi, such as Fusarium, accounted for most corneal infections associated with refractive contact lens wear, while yeasts, namely Candida, caused most of the fungal corneal infections in patients using a therapeutic lens.[10]

Long-term use of BCL along with steroid eye drops in Kpro patients makes them vulnerable to infections. Cleaning or replacing the contact lens on a regular basis and educating the patients about symptoms and signs of early infection will help to avoid sight-threatening complications. Since complications from microbial keratitis can occur in Kpro months after initial presentation, close monitoring is recommended after infection, with some patients still requiring surgical treatment later because of progressive corneal thinning.[11]

To the best of our knowledge, till date, all the case reports published on microbial keratitis following Kpro involve the spread of infiltrate into the Kpro/corneal graft and our case differs in that we recognized the infiltrate while it was over the BCL, and hence, its timely removal helped us to prevent the spread of infiltrate into the Kpro.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khan B, Dudenhoefer EJ, Dohlman CH. Keratoprosthesis: An update. Curr Opin Ophthalmol 2001;12:282-7.  Back to cited text no. 1
    
2.
Saeed HN, Shanbhag S, Chodosh J. The Boston keratoprosthesis. Curr Opin Ophthalmol 2017;28:390-6.  Back to cited text no. 2
    
3.
Chew HF, Ayres BD, Hammersmith KM, Rapuano CJ, Laibson PR, Myers JS, et al. Boston keratoprosthesis outcomes and complications. Cornea 2009;28:989-96.  Back to cited text no. 3
    
4.
Iyer G, Srinivasan B, Agarwal S, Talele D, Rishi E, Rishi P, et al. Keratoprosthesis: Current global scenario and a broad Indian perspective. Indian J Ophthalmol 2018;66:620-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kammerdiener LL, Speiser JL, Aquavella JV, Harissi-Dagher M, Dohlman CH, Chodosh J, et al. Protective effect of soft contact lenses after Boston keratoprosthesis. Br J Ophthalmol 2016;100:549-52.  Back to cited text no. 5
    
6.
Szczotka-Flynn LB, Pearlman E, Ghannoum M. Microbial contamination of contact lenses, lens care solutions, and their accessories: A literature review. Eye Contact Lens 2010;36:116-29.  Back to cited text no. 6
    
7.
Kim MJ, Yu F, Aldave AJ. Microbial keratitis after Boston type I keratoprosthesis implantation: Incidence, organisms, risk factors, and outcomes. Ophthalmology 2013;120:2209-16.  Back to cited text no. 7
    
8.
Sharma N, Falera R, Arora T, Agarwal T, Bandivadekar P, Vajpayee RB. Evaluation of a low-cost design keratoprosthesis in end-stage corneal disease: A preliminary study. Br J Ophthalmol 2016;100:323-7.  Back to cited text no. 8
    
9.
Venugopal A, Rathi H, Rengappa R, Ravindran M, Raman R. Outcomes after auro keratoprosthesis implantation: A low-cost design based on the boston keratoprosthesis. Cornea 2016;35:1285-8.  Back to cited text no. 9
    
10.
Wilhelmus KR, Robinson NM, Font RA, Hamill MB, Jones DB. Fungal keratitis in contact lens wearers. Am J Ophthalmol 1988;106:708-14.  Back to cited text no. 10
    
11.
Davies E, Chodosh J. Infections after keratoprosthesis. Curr Opin Ophthalmol 2016;27:373-7.  Back to cited text no. 11
    


    Figures

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



 

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