PMC9082142_01
a Slit-lamp microscopy image of the patient's left eye showing a small-sized infiltrate and corneal endothelial plaque at 2-weeks after initial presentation. b Corneal perforation and iris herniation occurred after 3 weeks after initial presentation.
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F1
Although a reduction in the size and density of the deep corneal infiltration was initially obtained (Fig. 1a), corneal perforation and iris herniation occurred 3 weeks after the initial examination. Moreover, fibrin formation was found around the pupil area and along to the corneal infiltration (Fig. 1b).
Slit-lamp microscopy image of the patient's left eye obtained at 2 weeks post-AMT. As can be seen in the image, the corneal perforation was closed with no recurrent corneal infection.
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F2
AMT with debridement around the perforated area was performed (Fig. 2). At the 5-month postoperative period, there were no signs of fungal infection, so the natamycin ophthalmic ointment and miconazole were discontinued, and treatment was switched to only a 4-times daily administration of gatifloxacin.
Slit-lamp microscopy images (a, b, d). We observed white corneal endothelial plaque that appeared at 6 months post-AMT (a), increased KPs at 7 months post-AMT (b) after tapering the daily antifungal treatment and increased corneal endothelial plaque (d) even after resuming intensive antifungal treatment at 12 months post-AMT. c Image of the smear examination of the centrifuged anterior-chamber humor showing yeast-like fungi (Fungiflora Y staining). e AS-OCT image showing a corneal endothelial plaque (white arrowheads) at 11 months post-AMT. KP, keratic precipitate; AS-OCT, anterior-segment optical coherence tomography.
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F3
However, at the 6-month postoperative period, an increase of keratic precipitates was observed (Fig. 3a). At the 7-month postoperative period, a further increase of keratic precipitates was observed, and adhesion of a pigmentary and white substance was observed on the amnion endothelial surface (Fig. 3b). Yeast-like fungi were detected (Fig. 3c) via Fungiflora Y staining of the aqueous humor, and Candida species were identified from culture. At the 11-month postoperative period, anterior-segment optical coherence tomography imaging revealed a high intensity of endothelial plaque material beneath the AMT region (Fig. 3e). Intravenous voriconazole and multiple injections of 1 mug/mL voriconazole into the anterior chamber (Fig. 3d) were ineffective, so at 1 year post-AMT, penetrating keratoplasty was performed.
a, b Microscopic images of pathological tissue samples post-PK. Image showing corneal endothelial plaque including many inflammation cells (white blood cells) and yeast-like fungi leading from the junction between the AM area and the residual cornea (a hematoxylin and eosin staining. b Fungiflora Y staining) (white arrowheads and arrows indicate endothelial plaque and the junction between the AM and the residual cornea, respectively). PK, penetrating keratoplasty.
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F4
Postsurgery, polymerase chain reaction testing showed a positive finding for fungal deposition in the posterior cornea, and immunohistochemistry of a specimen using Fungiflora Y staining revealed fungal deposition throughout the posterior plaque between the transplanted AM and the residual stroma (Fig. 4).
Slit-lamp microscopy image of the patient's left eye at 1.5-years post-PK showing no recurrent corneal infection. PK, penetrating keratoplasty.
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F5
At 1.5 years post-penetrating keratoplasty, no recurrence of fungal infection was found, and the best-corrected visual acuity in her left eye was 6/60 (Fig. 5).