|Year : 1977 | Volume
| Issue : 4 | Page : 37-40
Keratoplasty in keratomycosis
IM Shukla, BU Tahalyani, R Hassan
J.N.M. Medical College & D.K. Hospital, Raipur (M.P.), India
I M Shukla
J.N.M. Medical College & D.K. Hospital, Raipur (M.P.)
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shukla I M, Tahalyani B U, Hassan R. Keratoplasty in keratomycosis. Indian J Ophthalmol 1977;25:37-40
Mycotic infection of the cornea is rarely primary. In most cases it follows a trauma or after the injudicious use of antibiotic corticosteroid combination. The use of corticosteroids reduces the local resistance of cornea to fungal infection and even if the steroids are stopped, such decreased resistance may persist for indefinite period  . The inhabitant fungus in the cul-de-sac of field workers in autumn, is about 80%, which is responsible for maximum incidence of keratomycosis in them , .
| Materials and Methods|| |
27 cases of keratomycosis attended Medical College D.K. Hospital, Raipur during 1972 to 1976. The age ranged from 20 to 70 years. All the cases underwent anti-fungal treatment with Hamycin drops 10,000 units per ml. one hourly. The other medical treatment given to almost all patients was subconjuctival crystalline penicilline, genticyn eye drops, Crooks collosal argentum etc. In two cases mycostatin was given orally. 14 cases recovered well and in them good vision was restored.
Due to inadequate availability of antifungal agents 5 eyes were lost, which were brought in the state of defective projection and were eviscerated. In the remaining 8 cases keratoplasty was performed.
In 5 cases out of eight, three cases were due to Aspergillus, one was due to penicillium and one was due to candida albicans. In remining three the species could not be identified but hyphae were seen in direct KOH examination [Table - 1],[Table - 2].
Two cases were undertaken for lamellar keratoplasty and in six cases penetrating keratoplasty was done. In one cases conjunctivoplasty was done prior to penetrating keratoplasty.
This was carried out in two cases in which the corneal lesion was circumscribed and only superficial lemallae were involved as seen under slit lamp examination. The diseased part of the cornea was removed and replaced by donor cornea. In one case preserved donor material was used and in the other case donor material was fresh. Interrupted 7.0 virgin silk was used for edge to edge suturing. The size of graft was 8 mm and 11 mm.
All the remaining six cases had undergone penetrating keratoplasty. The size of the graft varied from 7 to 10 mm and edge to edge suturing was done by 7.0 virgin silk. The established technique was applied in cutting the graft and suturing. The anterior chamber was irrigated in two cases and total penetrating keratoplasty was done in two cases.
Post operative treatment
Daily dressing with antibiotic and atropine was done, corticosteroid was added after 10th to 15th day onwards. Stiches were removed after 3 to 4 weeks.
| Observation and Results|| |
Lamellar Keratoplasty [Table - 2]
Case No. 1: In the first case of lamellar keratoplasty due to tearing up of the fresh donor material, a preserved cornea was used. Transparency was maintained for 11 days. The graft became hazy and edematous with graft reaction. The graft was rejected from the bed on 24th day. The graft bed was free from infection and healed within 20 days leaving a macular opacity.
Case No. 2: In second case 11 mm and 0.6 mm thick lamellar keratoplasty was done. Graft was edematous and infected in the very 1st dressing. Graft was rejected on 3rd day. The infection continued and the eye went in to endophthalmitis leading to phthisis.
Penetrating keratoplasty [Table - 1]
In all the six cases the infection was controlled. The size of the graft varied from 8 mm to 10 mm. In one case only, there was defective projection preoperatively and in rest it was present all the four quadrants. In one case the graft became semi-transparent, in two cases the graft was clear and in rest of the two cases it became opaque. One patient died 24 hours after the operation due to cardiac arrest on the table.
The visual improvement was 6/36 in one patient and in another patient where total penetrating keratoplasty was done, vision improved to 6/60 after full correction.
| Post Operative Complications|| |
1. Graft reaction: This was seen all cases which became opaque and was noticed during second post operative week of operation. This was treated by 2 hourly corticosteroid drops but the graft became opaque after 3 weeks.
2. Graft ectasia:-It was seen in one case and was treated by firm bandage and diamox.
3. Graft ulceration: This was noted on 11th day in one case which went for perforation and prolapse of iris. The patient was not willing for second operation and so was treated conservatively.
| Discussion|| |
Norman Sanders  advocates penetrating keratoplasty for the cases which failed to respond to medical treatment. He obtained good visual activity in three cases of 15 penetrating grafts.
Devoc  advocated deep lamellar karatoplasty for mycotic keratitis. He had reported one case of mycotic corneal ulcer with penetrating keratoplasty which controlled the infection, saved the eye ball structurally, but the visual outcome was nil.
Gurubax and Malik  reported 7 cases of Lamellar keratoplasty and 10 cases of penetrating keratoplasty for keratomycosis. According to them penetrating keratoplasty is the procedure of choice for fungus infections and lamellar graft invariably fails because the fungus is able to penetrate descmet membrane.
Ross and Laibson  have shown that mycotic infection is usually secondary and have reported one case of penetrating keratoplasty in which the eye was saved structurally without visual improvement.
In the present series out of two Lamellar keratoplasty in one case the infection could be controlled and the eye ball saved while the other was lost.
Penetrating keratoplasty has been found to be the procedure of choice in cases not responding to medical treatment. But for one case who died of cardiac arrest, there was control of infection and eradication of the disease in all cases. In 2 cases out of 6 penetrating keratoplasty there was good visual improvement.
| Summary|| |
In eight cases of fungal keratitis where medical treatment failed, keratoplasty was carried out. In two cases lamellar and 6 cases penetrating keratoplasty was done.
Penetrating keratoplasty is found to be the best for such cases as it controlled the infection and eradicated the diseases in all cases.
Lamellar keratoplasty was found to be a total failure as regard improvement of vision.
| References|| |
Arthur Gerard Devoc, 1972, Amer. J. Ophthal.,
Gurbax and Malik, 1972, Brit. J. Ophthal., 56,41
Hymon, W. Ross and Peiter R. Laibson, 1972, Amer. J. Ophthal.,
Norman Sanders, 1970, Amer. J. Ophthal., 70,
Olson, C.L., 1969, Arch. Ophthal., 81,
Yahya, O.A., Klilliamson J. Gerdar, A.M. Fyer, 1969, Brit. J. Ophthal., 25,
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1], [Table - 2]