**2.2 Fungal keratitis**

The therapeutic keratoplasty has an important role in the refractory mycotic ulcers treatment. In a series published by Ibrahim MM et al in 2009 in Brasil, 66 patients with

Therapeutic Keratoplasty for Microbial Keratitis 17

infections and *Candida albicans* in contact lens user, and the patient came to be examined 2 to

The ulcers observed were indolent, with satellite lessons in 30% patients, irregular edges, dense infiltrate and hypopyon, ciliary injection in conjunctiva, Figs .8, 9, 10, 11 usually

Fig. 10. Hyphal elements visible on pathologic examination of corneal button. Schiff stain

Fig. 11. Septate hyphal fungus cells in the corneal scrap smears of fungal keratitis patients, stained with calcofluor (Cellfluor) and fluorescens microscopy ( 20X magnification)

The antifungal treatments were started immediately after the diagnosis was confirmed in each case. The total 81% of patients were treated with monotherapy and 18.4% patients with combined antifungal therapy. As antifungal therapy, 2% ketoconazole suspensión was prepared using 200 mg tablets (Nizoral®, Janssen Cilag, Mèxico City), manually crushed to fine poder and suspended in hidroxypropylmethyl-cellulose eye drops. A total of 14 of 27 (51.2%) cases also received oral ketoconazole 200-400 mg every 24 hours. Nine patients were

treated before with antibacterial drops without clinical healing.

6 weeks after the trauma.

(20X magnification).

mycotic ulcer, therapeutic keratoplasty was required in 38% of cases; the most frequent isolated etiological agent was *Fusarium* in 67%, *Aspergillus* 10.5% and *Candida* 10%.

In several studies published by Perez-Balbuena et al. 2009, Vanzzini et al. **2010**, the main fungal pathogens for keratitis in Mexico are *Fusarium solani* and other species, dematiaceous fungus that include a wide group of black colony forming fungus and *Aspegillus* with several species too.

Fig. 8. *Fusarium* large corneal ulcer 10 days after injury with organic material.

Fig. 9. Successful postoperative the same eye outcome six months after therapeutic keratoplasty loose suture after surgery

In a retrospective survey carried out from 1981 to 2001 in the Cornea Service of "Asociacion para Evitar la Ceguera en Mexico Hospital "Dr. Luis Sanchez Bulnes", we studied 120 cases of mycotic keratitis selecting 61 cases whose etiological agent was *Fusarium solani,* confirmed by the cultures. In total, 78% were male (average, age, 41.5 years) the principal risk factor was ocular trauma contaminated with organic material, dry eye, post corneal surgery in

mycotic ulcer, therapeutic keratoplasty was required in 38% of cases; the most frequent

In several studies published by Perez-Balbuena et al. 2009, Vanzzini et al. **2010**, the main fungal pathogens for keratitis in Mexico are *Fusarium solani* and other species, dematiaceous fungus that include a wide group of black colony forming fungus and *Aspegillus* with

isolated etiological agent was *Fusarium* in 67%, *Aspergillus* 10.5% and *Candida* 10%.

Fig. 8. *Fusarium* large corneal ulcer 10 days after injury with organic material.

Fig. 9. Successful postoperative the same eye outcome six months after therapeutic

In a retrospective survey carried out from 1981 to 2001 in the Cornea Service of "Asociacion para Evitar la Ceguera en Mexico Hospital "Dr. Luis Sanchez Bulnes", we studied 120 cases of mycotic keratitis selecting 61 cases whose etiological agent was *Fusarium solani,* confirmed by the cultures. In total, 78% were male (average, age, 41.5 years) the principal risk factor was ocular trauma contaminated with organic material, dry eye, post corneal surgery in

keratoplasty loose suture after surgery

several species too.

infections and *Candida albicans* in contact lens user, and the patient came to be examined 2 to 6 weeks after the trauma.

The ulcers observed were indolent, with satellite lessons in 30% patients, irregular edges, dense infiltrate and hypopyon, ciliary injection in conjunctiva, Figs .8, 9, 10, 11 usually treated before with antibacterial drops without clinical healing.

Fig. 10. Hyphal elements visible on pathologic examination of corneal button. Schiff stain (20X magnification).

Fig. 11. Septate hyphal fungus cells in the corneal scrap smears of fungal keratitis patients, stained with calcofluor (Cellfluor) and fluorescens microscopy ( 20X magnification)

The antifungal treatments were started immediately after the diagnosis was confirmed in each case. The total 81% of patients were treated with monotherapy and 18.4% patients with combined antifungal therapy. As antifungal therapy, 2% ketoconazole suspensión was prepared using 200 mg tablets (Nizoral®, Janssen Cilag, Mèxico City), manually crushed to fine poder and suspended in hidroxypropylmethyl-cellulose eye drops. A total of 14 of 27 (51.2%) cases also received oral ketoconazole 200-400 mg every 24 hours. Nine patients were

Therapeutic Keratoplasty for Microbial Keratitis 19

Patient with acanthamoebic keratitis are tipically young, healthy individuals, males or females are equally affected, almost all are daily contact lens wearer, or using non sterile wather for wash the contact lenses, is most frequently is an unilateral keratitis but bilateral cases have ocurred. The most important clinical sign is a severe pain even with a small epithelial dendritiform ulcer because the recurrent epithelial breakdown like an herpetic ulcer in the early stages of the infection. Some patients have a stage of disease mimicking disciform stromal keratitis and others develop radial neuritis. The occurrence of satellite lesions, stromal abscess, necrotizing inflammation, hypopyon, scleral nodules, diffuse scleritis or posterior scleral inflammation are signals of advanced infection. Figs. 12, 13 The most characteristic stromal antigen-antibody inflammatory reaction is the stromal ring formation that can consist of single, multiple or overlapping rings around the main corneal

The ophthalmic pathology caused by *Acanthamoeba* might produce severe and extensive corneal necrosis that tome times require therapeutic keratoplasty. The evolution of an infection becomes in a severe stromal keratitis of late diagnosis, inadequate treatment and severe consequences. Despite is rare pathology, in the last decade are incremented its

Before carrying out a therapeutic keratoplasty it is important to give a medical therapy and many drugs have been tested for *Acanthamoeba* infections as mentioned in the Box No 1, the most used are Chlorexidine 0.01% in aqueous solution not commercially available, Polimethylene biguanide 0.3% in aqueous solution (Brolene® UK). Oral Itraconazole 100 mgs/ 12 hours combined with topical Netilmycin 0.3% (Netira® SCIFI laboratories Italy) are

Fig. 12. *Acanthamoeba* keratitis in young and healthy female patient, 6 weeks evolution time,

Laboratory diagnosis are better done by visualizing cyst cells in the mucous exudate or in corneal biopsies, by stain tecniques like Giemsa Fig. 13 or Calcofluor (Cellfluor) and fluorescence ligth microscopy and by cultures C in non nutrient Pages medium with a layer

frequency, associated to contact Lents user. Ficker LA et al 1993.

actually used in our acanthamoebic keratitis patient.

ulcer. Alizadeh H, et al 1998

edema, and central ulcer.

of inactivated cells of *Enterobacter aerogenes.* 

treated with topical itraconazole 1.0% drops (Sporanox®, Janssen-Cilag, Mèxico City) made in the same way as ketoconazole. Perez-Balbuena et al. 2009

The Fluconazole (2mg/ml Diflucan®, Pfizer) topical drops were made with intravenous solution of 2 mg/mL with <1mg/mL (0.66 mg) in final concentration using hidroxypropylmethyl-cellulose eye drops.

Severe cases were assigned to the medical and surgical treatment, using either monotherapy or combined topical antifungal treatment plus one or more surgeries. Therapeutic keratoplasty was indicated in 14/61 patients 23%. Conjuntival flap was indicated en 4 of 61 patients 6.5%, eviscearation surgeries were practiced in 14 of 61 patients 22.9%.

For medical treatment actually we use Natamycin 5% suspension in ocular droops (Miconacina® Grin laboratorios Mexico City) each 1 hour initially for two days, and after each 4 hours for 8 to 15 days upon the clinical response, we use this last dosage at least for 30 to 40 days, in cases of *Aspergillus* keratitis the medication mentioned before is associated with oral Itraconazole 100 mgs/ 12 hours. For *Candida* keratitis we use topical Voriconazole 1% (V-Fend® Pfizer Germany)) or Fluconazole 1% (Diflucan® Pfizer Germany). The indications for therapeutic keratoplasty included minimun improvement with medical therapy or high perforation risk. Table 1


Medical / Surgical Therapy group

Table 1. Antifungal therapy used in the medical and surgery group

Killingsworth et al. 1993 obtained a 100% recovery in 15 ulcers treated with therapeutic Keratoplasty. We suggested surgical therapy with conjunctive flap or penetrating keratoplasty in advanced cases when there has been a poor response to medical therapy or a very low final visual acuity.

#### **2.3 Acanthamoeba keratitis**

The ophthalmic pathology caused by *Acanthamoeba* might produce severe and extensive corneal necrosis that tome times require therapeutic keratoplasty. The evolution of an infection becomes in a severe stromal keratitis of late diagnosis, inadequate treatment and severe consequences.

treated with topical itraconazole 1.0% drops (Sporanox®, Janssen-Cilag, Mèxico City) made

The Fluconazole (2mg/ml Diflucan®, Pfizer) topical drops were made with intravenous solution of 2 mg/mL with <1mg/mL (0.66 mg) in final concentration using

Severe cases were assigned to the medical and surgical treatment, using either monotherapy or combined topical antifungal treatment plus one or more surgeries. Therapeutic keratoplasty was indicated in 14/61 patients 23%. Conjuntival flap was indicated en 4 of 61

For medical treatment actually we use Natamycin 5% suspension in ocular droops (Miconacina® Grin laboratorios Mexico City) each 1 hour initially for two days, and after each 4 hours for 8 to 15 days upon the clinical response, we use this last dosage at least for 30 to 40 days, in cases of *Aspergillus* keratitis the medication mentioned before is associated with oral Itraconazole 100 mgs/ 12 hours. For *Candida* keratitis we use topical Voriconazole 1% (V-Fend® Pfizer Germany)) or Fluconazole 1% (Diflucan® Pfizer Germany). The indications for therapeutic keratoplasty included minimun improvement with medical

Medical / Surgical Therapy group

Penetrating keratoplasty

Tectonic keratoplasty

Eviscerations

Tome of Treatment Days

val Flap

Natamycin 0 0 0 0 0 0 ketoconazole 11 0 4 1 7 20.6 Miconazole 0 0 0 0 0 0 Itraconazole 3 2 2 1 2 26 Fluconazole 1 1 0 0 1 40

+Fluconazol 1 0 1 0 0 15 Ketoconazole+Itraconazole 1 0 1 0 0 20 Ketoconazole+Fluconazole 3 0 1 0 2 78.3 Itraconazole+ Fluconazole 2 0 2 0 0 47 Natamycin+ Fluconazole 1 1 1 0 0 170 Ketoconazole+ Miconazole 1 0 0 0 1 20 No treatment and lost follow-up 4 0 3 0 1 0

Killingsworth et al. 1993 obtained a 100% recovery in 15 ulcers treated with therapeutic Keratoplasty. We suggested surgical therapy with conjunctive flap or penetrating keratoplasty in advanced cases when there has been a poor response to medical therapy or a

The ophthalmic pathology caused by *Acanthamoeba* might produce severe and extensive corneal necrosis that tome times require therapeutic keratoplasty. The evolution of an infection becomes in a severe stromal keratitis of late diagnosis, inadequate treatment and

Total 28 4 15 2 14

Table 1. Antifungal therapy used in the medical and surgery group

patients 6.5%, eviscearation surgeries were practiced in 14 of 61 patients 22.9%.

in the same way as ketoconazole. Perez-Balbuena et al. 2009

Drug n Conjuncti-

hidroxypropylmethyl-cellulose eye drops.

therapy or high perforation risk. Table 1

Ketoconazole+Natamicycin

very low final visual acuity.

**2.3 Acanthamoeba keratitis** 

severe consequences.

Patient with acanthamoebic keratitis are tipically young, healthy individuals, males or females are equally affected, almost all are daily contact lens wearer, or using non sterile wather for wash the contact lenses, is most frequently is an unilateral keratitis but bilateral cases have ocurred. The most important clinical sign is a severe pain even with a small epithelial dendritiform ulcer because the recurrent epithelial breakdown like an herpetic ulcer in the early stages of the infection. Some patients have a stage of disease mimicking disciform stromal keratitis and others develop radial neuritis. The occurrence of satellite lesions, stromal abscess, necrotizing inflammation, hypopyon, scleral nodules, diffuse scleritis or posterior scleral inflammation are signals of advanced infection. Figs. 12, 13 The most characteristic stromal antigen-antibody inflammatory reaction is the stromal ring formation that can consist of single, multiple or overlapping rings around the main corneal ulcer. Alizadeh H, et al 1998

The ophthalmic pathology caused by *Acanthamoeba* might produce severe and extensive corneal necrosis that tome times require therapeutic keratoplasty. The evolution of an infection becomes in a severe stromal keratitis of late diagnosis, inadequate treatment and severe consequences. Despite is rare pathology, in the last decade are incremented its frequency, associated to contact Lents user. Ficker LA et al 1993.

Before carrying out a therapeutic keratoplasty it is important to give a medical therapy and many drugs have been tested for *Acanthamoeba* infections as mentioned in the Box No 1, the most used are Chlorexidine 0.01% in aqueous solution not commercially available, Polimethylene biguanide 0.3% in aqueous solution (Brolene® UK). Oral Itraconazole 100 mgs/ 12 hours combined with topical Netilmycin 0.3% (Netira® SCIFI laboratories Italy) are actually used in our acanthamoebic keratitis patient.

Fig. 12. *Acanthamoeba* keratitis in young and healthy female patient, 6 weeks evolution time, edema, and central ulcer.

Laboratory diagnosis are better done by visualizing cyst cells in the mucous exudate or in corneal biopsies, by stain tecniques like Giemsa Fig. 13 or Calcofluor (Cellfluor) and fluorescence ligth microscopy and by cultures C in non nutrient Pages medium with a layer of inactivated cells of *Enterobacter aerogenes.* 

Therapeutic Keratoplasty for Microbial Keratitis 21

In eyes with a crystalline lens or posterior chamber intraocular lens, and patients with iris incarcerated in a wound, we give Pilocarpina 2% 1 hour prior to surgery, to protect the lens,

We do not recommend carrying out the surgery with local anesthesia, it is much better to perform it under general anesthesia and in all cases we must maintain the arterial pressure under control to reduce the risk of expulsive choroidal hemorrhage, especially in those

Before therapeutic keratoplasty for infectious keratitis, the patient should be treated with topical and systemic therapy directed towards the offending microbe. This treatment applies

Regardless of the infectious etiologies, we always recommend topical antbiotic therapy to

The preoperative antibiotic prophylaxis should be broad spectrum and nontoxic to help promote reepithelization and prefer an antibiotic that penetrates into the cornea, aqueous

We currently use a topical fourth –generation fluoroquinolone Gatifloxacin 0.3% (ZymarR; Allergan Inc, Irvine, CA) with a saturating dosage of one drop every 15 minutes for 1 hour

Criteria for the selection of donor corneas are stringent, except in cases of large perforation when access to tissue of optimal quality is not possible. Corneal tissue of excellent grade

**5.1**. Healthy tissue with intact epithelium minimizes the risk of re infection in the graft and

**5.2.** Compact and clear tissue helps in monitoring anterior chamber reaction during the

Yao et al. 2003. If fresh donor tissue is not available, the use of cryopreserved tissue and donor corneas preserved in pure glycerin or water-free calcium chloride are effective substitutes in therapeutic keratoplasty to control severe fungal corneal infection and

Although corneal transplantation for infections keratitis follows the basic surgical technique

We recommend general anesthesia .It is important to have a soft eye preoperatively so that

of penetrating keratoplasty, special attention must be given to certain details:

problems related to positive vitreous pressure can be prevented.

Before surgery, intraocular pressure should be evaluated in eyes without a perforation. Adequate pressure control remains essential. In patients with markedly elevated intraocular pressure or in patients with a corneal perforation in which the lens-iris-diaphragm has moved forward, we give intravenous manitol to control intraocular pressure and to reduce

the vitreous volume.

patients with perforation.

**4. Preoperative treatment** 

to bacterial, fungal and *Acanthamoeba.* 

achieve levels above to MIC90 of most pathogenic bacteria.

use of healthy endothelium is critical for the survival of the graft.

prevent bacterial super infection.

offers the following advantages:

immediate postoperative period.

preserve the global integrity.

**6. Surgical techniques** 

**6.1 Preoperative procedures** 

before keratoplasty.

**5. Donor material** 

and maintain a posterior lens-iris diaphragm.

Fig. 13. *Acanthamoeba* cyst Giemsa stein, in light microscope view (20 X magnification)

Before carrying out therapeutic keratoplasty it is important to give a medical therapy and many drugs have been tested for *Acanthamoeba* infections as mentioned in the , the most used are Chlorexidine 0.01% in aqueous solution not commercially available, Polimethylene biguanide 0.3% in aqueous solution (Brolene ®UK) we used in our

Oral Itraconazole 100 mgs/ 12 hours combined with topical Netilmycin 0.3% (Netira® SCIFI laboratories Italy) are actually used in our acanthamoebic keratitis patient. Medical and surgical treatment in Keratitis by *Acanthamoeba* is controversial.

In some cases with early diagnosis these cases have been successfully treated with medical treatment without being necessary to undergo a surgical procedure of therapeutic keratoplasty. Ficker et al 1993, mention that the over life of the graft by Keratitis by *Acanthamoeba* is of poor outcome, reporting more than 50% recurrence incidence of the graft. However, in our personal opinion, the Keratoplasty continues to have a central role in the management of patients who progress or do not respond to medical treatment. The acute management of these active cases is to sterilize the infection as rapidly as posible and to dalay surgical management until the patient receives adequate antiamebic therapy.
