a 42-year - old lady with granular dystrophy underwent dalk in the left eye with big bubble technique . at first 8 mm of recipient stromal flap was partially dissected from the surface , then air was injected into the substance of the remaining stroma . this would enable air to pass in the plane between the descemet membrane ( dm ) and the deepest stroma so that the stroma can easily be separated from the dm , leaving bare dm . the donor button was cut 8.25 mm ; its dm was peeled off and was placed over the recipient dm and sutured with recipient rim . the surgery had gone quite well , but to our alarm , on the first postoperative day ( pod ) , there was whitish infiltrates along the graft - host junction almost 180 with severe anterior chamber reaction . on the same day , the graft was removed and replaced by another stromal graft . because the host dm was clear and intact , we preferred not to convert the procedure into pk , although there was thin line of residual infiltrates in the host rim . three hours after the surgery topical vancomycin ( 50 mg / ml ) and ceftazidime ( 100 mg / ml ) were started hourly during day and two hourly at night . gram - stain showed presence of gram - negative bacilli . on the next day of repeat - deep anterior lamellar keratoplasty ( redalk ) , the clinical picture was even worse with infiltrates along the entire graft host junction and hypopyonfig . report of the corneal scrapings and corneal button , both revealed klebsiella pneumoniae resistant to cefazolin , amikacin , vancomycin , ceftazidime , ofloxacin , ciprofloxacin , moxifloxacin , cefixime , chloramphenicol , tetracycline , gentamicin , and cefalexin . imipenem ( 5 mg / ml ) drops was started hourly during day and two hourly at night . despite this , the infiltration extended toward center of graft and hypopyon persisted [ fig . 2 ] . four days later , large diameter ( 9.5 mm donor , 9 mm recipient ) therapeutic penetrating keratoplasty ( tpk ) was carried out during which infiltrates were observed also in host dm , which was not there during redalk . first postoperative day of therapeutic deep anterior lamellar keratoplasty showing infiltrates in the rim , hypopyon and epithelial defect extension of the infiltrate seen in the sixth postoperative day of therapeutic deep anterior lamellar keratoplasty at 6 weeks , unaided vision was 6/60 improving to 6/18 with pin hole . her graft was clear , anterior segment was quiet with normal intraocular pressure and eradication of the pathogen [ fig . sharma et al . reported 11% incidence of postoperative keratitis after anterior lamellar keratoplasty ; in two cases , tpk had to be done and the most common organism was staphylococcus . epithelial defect , suture abscess , vernal keratoconjunctivitis , recurrent herpetic keratitis were the predisposing factors . in our case , reported a similar case of keratitis after dalk with multidrug resistant k. pneumonia , which completely resolved with sensitive antibiotic , imipenem 5 mg / ml whereas our patient did not . in redalk , we had left some residual infiltrates , as we had not known about the multidrug resistant organism and because , the dm was clear , we hesitated to do pk . they had done culture of corneoscleral rim , which showed klebsiella the sensitivity pattern of which matched with the isolate from the transplanted graft . although , literatures show that donor corneoscleral rim culture report lacks predictability about postoperative infections , the donor cornea could be the reason for contamination in their case . in eye bank from where we obtained donor cornea , corneoscleral culture is not routinely done . nor was it done at the time of surgery . . showed a statistically significant increase in contamination of donor rims with preservation time of more than 5 days . in our case , recovery time was 6 hours after death and preservation time in mccarey kaufman ( mk ) media was 72 hours . . risk factors for nosocomial infection include advanced age , prolonged illness , treatment with many antibiotics , mechanical ventilation , and long hospital stays . this could be the explanation for donor contamination in the case report by egrilmez et al . in which the donor was under long - term intensive care . in our case , the recipient was healthy and so was the donor , who died at the age of 36 years due to fall from height ; death was declared on reaching the emergency of the donor hospital . nevertheless we can not deny acquisition of the organism from this hospital because in a recent study , tada et al . had isolated multidrug resistant k. pneumoniae from samples ( pus and sputa ) of 25 in patients of this hospital . in this report , all the isolates were resistant to piperacillin , ceftazidime , cefotaxime , cefepime , aztreonam , 17 were resistant to imipenem and meropenem , 20 were resistant to all aminoglycosides tested , and 22 were resistant to ciprofloxacin . however , the fellow donor cornea , with the same preservation media when was transplanted to another recipient on the same operating table , on the same day , had uneventful postoperative period . air microbiology of operation theatre taken on the second pod of dalk , revealed staphylococcus , micrococcus and occasionally gram - positive bacilli within acceptable range . swabs taken from microscope , operating tables and chairs also gave similar results , whereas those from autoclaved surgical instruments and gowns were sterile . considering all the factors , donor hospital acquired contamination of the corneal tissue is the most likely explanation . donor person high risk for nosocomial infection should be a relative contraindication for cornea recovery because of severe nature of hospital acquired infection . even if donor rim cultures are not done routinely , one could keep the residual donor rim for a few days in the mk medium instead of discarding the rim on the day of surgery , and this can be subsequently cultured in case of postoperative sepsis .
a healthy lady of 42 years underwent deep anterior lamellar keratoplasty for granular dystrophy . 
 the very next day , it was complicated by development of infectious keratitis . 
 the organism was identified as multidrug resistant klebsiella pneumoniae . 
 donor corneal button may be implicated in the transmission of infection in an otherwise uneventful surgery and follow - up . 
 nosocomial infections are usually severe , rapidly progressive and difficult to treat . 
 finally , the lady had to undergo therapeutic penetrating keratoplasty for complete resolution of infection .