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Sclérocorneoplastie centrale "à chaud" chez un cas de kératite fongique superinfée sur base de kératite herpetique réccurente

Mycotic keratitis is a rare and feared disease with an often fast-progressing course. It requires an early diagnosis and usually a rapid microsurgical intervention. This case report describes the successful management of a bacteria-superinfected mycotic keratitis based on recurrent herpetic infections by means of a sclerocorneal graft and postoperative repeated anterior chamber irrigations with drug administration.

A 78-year-old patient with a history of recurrent herpetic keratitis was admitted with a suspected recurrence of  the disease. The patient had severe pain and massive visual loss (hand motion) in the right eye, which has already been treated with topical and systemic antiherpetic medication.

Slit lamp biomicroscopy showed a deep stromal infiltration of the entire cornea, through which no anterior chamber details were recognizable. Confocal microscopy revealed multiple fungal hyphae, which consequently resulted in performing a penetrating keratoplasty à chaud with a large sclerocorneal graft (11.0/12.0 mm) using 32 single sutures. Simultaneously, an anterior chamber irrigation with intracameral administration of vancomycin, ceftazidime, voriconazole, and amphotericin B was carried out.

Since herpes simplex virus and Acinetobacter Iwoffii were detected postoperatively in the excised cornea by PCR and histology, antiviral (topical ganciclovir, systemic aciclovir) and antibiotic (topical moxifloxacin) therapy were also administrated in addition to the antifungal (topical voriconazole, topical amphotericin B, systemic fluconazole) treatment. At discharge, fluconazole was discontinued, whereas systemic immunosuppression and steroids were added to the therapy scheme. At the 6 month follow-up examination, the best-corrected decimal visual acuity of the affected eye was 0.6 and the graft was clear without signs of rejection.

In case of a therapy-resistant deep corneal infiltration, mycotic infection should be considered even in case of known recurrent herpes keratitis. A fast diagnosis using confocal microscopy is indispensable in order to initiate an adequate therapy and is often the key to the required prompt therapeutic approach.

An early keratoplasty à chaud with large graft diameter and 32 single-sutures, in combination with intensive postoperative antifungal, antibacterial, and antiviral therapy led to a successful outcome of this „triple keratitis“.