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Administration of steroids for immune rejection after keratoplasty in patients with fungal keratitis

May 22 2017

In a prospective observational study performed at Shandong Eye Hospital between January  2009 – April 2014; Wang et al evaluated the introduction of the low dose steroid (0.02% fluorometholone eye drops) one week following corneal transplantation for proven fungal keratitis. The rates of anterior chamber inflammation, graft rejection and recurrence of fungal keratitis where observed.

Patients who had received topical steroids before surgery were excluded; as were patients with a hypopyon and raised intraocular pressure. Patients with corneal perforation and corneal infection expanding to the limbus were also excluded.

244 patients were enrolled with proven fungal keratitis. Diagnoses were confirmed by culture of corneal scrapings; or by direct visualisation of hyphae by Confocal Microscopy or histopathology of the partial corneal buttons.  224 specimens were culture positive among which 165 (73.66 %) were identified as Fusarium species, 30 (13.39 %) as Aspergillus species, 20 (8.93 %) as Alternaria species, and 9 (4.02 %) as other species.

Patients received hourly topical antifungal treatment of either; 0.5 % fluconazole combined with 0.25 % amphotericin B or 5 % natamycin. In addition, 100 milligrams of intravenous fluconazole was given twice daily. Corneal ulcers that deteriorated or would not improve after 5-10 days were considered for corneal transplantation by either Penetrating Keratoplasty (118 underwent PK with intraoperative irrigation of the anterior chamber angle and iris surface with 0.2% fluconazole) or Lamellar Keratoplasty (126 underwent LK).

Post surgically patients would receive topical 0.5 % fluconazole, and 0.25% amphotericin B or 5% natamycin four times a day initially. In addition to topical fluoroquinolone eye drops, non-steroidal anti-inflammatory eye drops and topical 1 % cyclosporine A eye drops. Patients also received Oral fluconazole, which was started one day before surgery and continued for three weeks. No patient showed signs of recurrent fungal infection, and administration of twice daily topical0.02 % fluorometholone was initiated at one week after keratoplasty. Once there was no sign of recurrence after 2 days, the dose was increased to four times daily, and dexamethasone ointment was added before bedtime. In the event of recurrence, corticosteroids were stopped.

Slit-lamp photographs showing that anterior segment inflammation after penetrating keratoplasty was controlled with the use of steroids. a Central full-thickness corneal fungal infection. b Anterior segment congestion and white infiltrates around the sutures at 5 days after penetrating keratoplasty. c Anterior segment congestion, white infiltrates around the sutures, and graft edema at 7 days. d The symptoms of immune rejection were relieved after 4 days of steroid use. (from Fig 3  Ting Wang & Suxia Li  & Hua Gao & Weiyun Shi  2016) 

Anterior segment inflammation was aggravated within one week after surgery, but was controlled at 7.51 ± 1.76 days after steroid use. Fungal keratitis recurred in three eyes (1.23 %) at 3 to 5 days after administration of corticosteroids, including two eyes receiving PK and one eye receiving LK.

Recurrence was controlled with antifungal medications. Allograft rejection occurred in eight (6.78 %) patients treated by PK, but did not occur in patients treated by LK.

 Article:  (Wang Li Gao and Shi:   Graefes Arch Clin Exp Ophthalmol (2016) 254:1585–1589)